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Full text of "United States Navy Medical News Letter Vol. 46 No. 11, 3 December 1965"

NAVMED P-5088 



"CJ3STITEO STATES TSTATV^T 

Medical News Letter 



Vol. 46 



Friday, 3 December 1965 



No. 11 




CONTENTS 



Surgeon General Receives 



MEDICAL ARTICLES 



Treatment of Pulmonary Embolic Disease 2 

Diagnosis and Treatment of Whipple's Disease 9 

Retroillumination of Retinal Vessels in Retinal 

Edema 1 ' 

FROM THE NOTE BOOK 

Surgeon's Tool 13 

Phenothiazines — Skin-Eye Syndrome 14 

Veterans Administration Meeting 14 

Symposium on Current Surgical Practices 14 

Naval Medical Research Reports 14 

DENTAL SECTION 

Antibacterial Activity and the Total Solids Content 

of Parotid Saliva to Caries Development 15 

Pulp Response to Cavity Drying in Rat Teeth 15 

A Suggestion That Collagen is a Third Class of 

Protein 16 

Treatment of Large Cysts of the Jaws 16 

Diseases of Teeth in 1578 16 

Personnel and Professional Notes 17 



3rd Star 1 

PREVENTIVE MEDICINE 

Variable Epidemiology of Streptococcal Disease and 
the Changing Pattern of Rheumatic Fever 18 

Boutonneuse Fever 20 

Ciguatera Poisoning 21 

Ticks 22 

Fleas — A Continuing Problem 23 

Know Your World 24 

EDITORIAL DESK 



Availability of Psychiatric Residencies in Naval 

Hospitals 25 

Not Just Another Baby 26 

Ether Peroxides 27 

Replacement of Blood Used by Family Members of 

Overseas Servicemen 28 

Medicare Program 28 

Navy Corpsman Cited for Bravery 29 



United States Navy 
MEDICAL NEWS LETTER 



Vol. 46 



Friday, 3 December 1965 



No. 11 



Vice Admiral Robert B. Brown MC USN 
Surgeon General 

Rear Admiral R. O. Canada MC USN 
Deputy Surgeon General 

Captain W. F. Pierce MC USN (Ret), Editor 

William A. Kline, Managing Editor 

Contributing Editors 

Aviation Medicine Captain Frank H. Austin MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine Captain J. H. Schulte MC USN 

Reserve Section Captain C. Cummings MC USNR 

Submarine Medicine Captain J. H. Schulte MC USN 



Policy 
The U.S. Navy Medical News Letter is basically an 
official Medical Department publication inviting the 
attention of officers of the Medical Department of the 
Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to 
medicine, dentistry, and allied sciences. The amount 
of information used is only that necessary to inform 
adequately officers of the Medical Department of the 
existence and source of such information. The items 
used are neither intended to be, nor are they, sus- 



ceptible to use by any officer as a substitute for any 
item or article, in its original form. All readers of the 
News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter 
to Editor: Bureau of Medicine and Surgery, Navy De- 
partment, Washington, D.C. 20390 (Code 18), giving 
full name, rank, corps, and old and new addresses. 



FRONT COVER: U.S. NAVAL HOSPITAL, YOKOSUKA, JAPAN. The U.S. Naval Hospital, Yokosuka, 
Japan is located within the confines of the U.S. Naval Fleet Activities, in the city of Yokosuka, Japan which 
has a population of 308,314 people and is located on the Miura Peninsula, approximately forty miles south of 
Tokyo. Construction by the Japanese Navy of what is now the U.S. Naval Hospital, Yokosuka, was com- 
menced on 31 March 1927 and completed on 20 February 1931. During World War II this hospital was 
occupied as an Imperial Japanese Navy Medical Center which included a Hospital Corps Training School 
and a Naval Hospital which had a normal staff of 237 and a war-time staff of 735 officers and men. The bed 
capacity was listed then as 578 normal, 690 maximum, and 857 emergency. The buildings in the present U.S. 
Naval Hospital compound are substantially the same as when it was originally constructed by the Japanese 
Navy. 

Shortly after the start of the Korean Conflict the U. S. Naval Hospital was established by the Secretary of 
the Navy and it was commissioned on 11 September 1950. The month of December 1950 brought the hos- 
pital's greatest work load, the peak in patient census being reached on 14 December 1950 when there were 
4.388 on the sick list. Once during this period there were 2.000 patients admitted within a 24 hour time span. 

In December 1951 the Secretary of the Navy awarded the Navy Unit Citation to the U.S. Naval Hospital, 
Yokosuka, "For extremely meritorious services in the treatment and hospitalization of 5,804 war casualties 
and other patients from 5 December 1950 to 15 January 1951." CAPT Walter F. James MC USN (later 
RADM rank) was the hospital's Commanding Officer at the time of the record patient load. 

The issuance of this publication approved by the Secretary of the Navy on 4 May 1964. 



U.S. NAVY MEDICAL NEWS LETTER 




Surgeon General Receives Third Star 

The Surgeon General of the Navy, Robert B. Brown, was promoted to the rank of vice admiral on Octo- 
ber 27, 1965. Legislation for three-star rank for the Surgeons General of the Army, Navy, and Air Force 
was sponsored by Congressman L. Mendel Rivers, Chairman of the House Armed Services Committee. 

Admiral Brown, obviously proud, remarked "This promotion is truly a recognition of the contributions of 
all of you in the Navy Medical Department, past and present, Reserve and Regular. I can only say that I am 
very happy to have been an incumbent of the office when this action was completed." 



U.S. NAVY MEDICAL NEWS LETTER 



TREATMENT OF PULMONARY EMBOLIC DISEASE* 

A Critical Review of Some Aspects of Current Therapy 

Duncan P. Thomas MD, PhD**, Boston, Mass. The New Eng J Med 273(17): 
885-892, October 21, 1965. 



The evidence continues to accumulate that pul- 
monary embolic disease represents a major cause of 
death, especially among patients in hospitals. Smith, 
Dexter and Dammin, in autopsy studies at the Peter 
Bent Brigham Hospital, Boston, found pulmonary 
embolism to be the single most common cause of 
death. Freiman found evidence of old or recent pul- 
monary emboli in 64 per cent of a group of consecu- 
tive patients autopsied at the Beth Israel Hospital, 
Boston. Morrell, Truelove and Barr, impressed by 
an apparent fivefold increase in the number of pa- 
tients given the diagnosis of pulmonary emboli at the 
United Oxford Hospitals in the past decade, con- 
cluded that this increase represented "one aspect of 
an epidemic of thrombotic disease at present affect- 
ing Western society." Although the importance of 
this disease is now generally recognized, and signifi- 
cant advances have been made in the areas of patho- 
genesis and diagnosis, the therapy of pulmonary em- 
bolic disease remains controversial. In fact, the 
therapeutic guidance that has been offered has been 
characterized as follows: ". . . some of it has been 
without experimental basis, some has been lacking 
in clinical sense, and the bulk has been woefully 
deficient in both." 

In this review, some of the therapeutic measures 
currently employed in the prophylaxis and treatment 
of pulmonary embolic disease will be examined in 
the light of current knowledge of the pathophysi- 
ology of the disease. The evidence for their effective- 
ness will be evaluated on the basis of present-day 
standards for clinical trials. Some recent work on 
experimental thromboembolism will be reviewed, 
although much will be omitted for the sake of 
brevity. 

Medical Management 

Experimental Background 

It has become clear in recent years that throm- 
bosis occurring in areas of stasis or low-velocity 



* From the Department of Medicine. Vascular Laboratory, Lemuel 
Shattuck Hospital, and the Tutts University School of Medicine 
** Chief, Vascular Laboratory, Lemuel Shattuck Hospital; assistant 
professor of medicine, Tufts University School of Medicine. 



blood flow, such as veins, represents a somewhat dif- 
ferent phenomenon from that occurring in areas of 
high-velocity blood flow. In the former type, the 
thrombus is more akin to a blood clot and is termed 
a red, or coagulation, thrombus. Arterial thrombi, 
on the other hand, have a different structure, and 
the fundamental event appears to be an initiating 
platelet nidus. Wessler, in stressing the difference 
between venous and arterial thrombi, has suggested 
that the two primary pathogenetic events in the 
formation of venous thrombi are local stasis, such as 
occurs in the leg veins, simultaneously combined with 
systemic altered coagulability of the blood. Accord- 
ing to this view of the pathogenesis of venous 
thrombi, therapeutic attempts should revolve around 
reducing venous stasis in the legs and countering the 
assumed systemic hypercoagulability. A detailed 
regimen of medical management based on these 
concepts has been outlined. 

It has been shown experimentally that venous 
thrombi neither form nor propagate in animals given 
sufficient heparin to prolong the glass clotting time 
to greater than twice the control value. Recent ob- 
servations in dogs have indicated that heparin may 
have an additional function in the treatment of pul- 
monary emboli, apart from preventing thrombus for- 
mation or propagation. After the release of autolo- 
gous venous thrombi to the lungs of dogs, intense 
airway constriction developed within one or two 
minutes, owing to the release of serotonin from plate- 
lets. However, if the dog was heparinized before 
the release of thrombi to the lungs, airway constric- 
tion did not develop. Heparin prevented the release 
of serotonin from platelets, probably by neutralizing 
thrombin still present on fresh thromboemboli. Ac- 
cording to this concept, thromboemboli obstructing 
segments of the pulmonary vasculature may have 
profound pharmacologic as well as mechanical 
effects by inducing the local release of platelet 
amines, resulting in airway constriction and vaso- 
constriction. The extent to which rapid smooth - 
muscle constriction in the airway and pulmonary 
vasculature contributes to the sudden death seen in 



U.S. NAVY MEDICAL NEWS LETTER 



pulmonary embolism remains conjectural. It is not 
without interest, however, that there are clinical 
reports indicating that fatal pulmonary embolism is 
very uncommon once a large dose of heparin has 
been administered intravenously. Bronchoconstric- 
tion observed in patients with acute pulmonary em- 
bolism was found to be partially reversed after 
heparin therapy, suggesting that thrombin-induced 
platelet amine release may occur in man. 

Prophylactic Therapy of Venous Thromboembolism 

The rationale for selected prophylactic therapy is 
based primarily on two well recognized clinical facts 
— namely, that certain patients are notoriously liable 
to have pulmonary emboli and that the diagnosis of 
venous thromboembolism is very difficult. It follows, 
therefore, that in certain high-risk groups, prophy- 
lactic therapy may be warranted. The classic paper 
of Sevitt and Gallagher demonstrated convincingly 
in a well controlled study that prophylactic anticoa- 
gulant therapy could virtually abolish thromboembol- 
ic complications in elderly patients with fracture of 
the neck of the femur. As Sevitt recognized, it is 
necessary to strike a balance between the indiscri- 
minate administration of anticoagulant therapy to 
every patient admitted to the hospital and its too 
narrow restriction. He found in injured patients that 
the great majority of cases of embolism occur in 
patients over forty-five years of age and that deep 
vein thrombosis is especially likely to occur in pa- 
tients over this age who are put to bed for more 
than three days. 

Sevitt's current policy is to institute oral prophy- 
laxis from the day of admission in all patients over 
the age of forty years with a fractured neck of the 
femur, other fractures of the femur, fractured tibia 
and fractured ankle. In his experience, hip pinning 
and nailing and other limb surgery can be carried 
out under phenindione therapy without the added 
danger of operative bleeding. Therapy is continued 
for one week beyond the time when the patient is 
ambulant. Salzman and his associates, at the Massa- 
chusetts General Hospital, have recently confirmed 
Sevitt's observations. They studied 187 patients with 
fracture of the neck of the femur, dividing them 
equally into control and treated groups. In their con- 
trol group, 8 patients had pulmonary emboli, with 4 
deaths. None of the patients on anticoagulant ther- 
apy suffered a pulmonary embolus. Dick et al., in 
another well controlled study, demonstrated the 
effectiveness of prophylactic anticoagulant therapy 
for venous thromboembolism. Bottomley, Lloyd and 
Chalmers, after ten years' experience with prophy- 



lactic anticoagulant therapy in postoperative gyneco- 
logic patients, considered the frequency of thrombo- 
tic disease to be reduced by a factor of five, although 
they did not have a concurrent control group of 
matched patients. It seems clear, therefore, that pro- 
vided the drug is given early, for sufficient time and 
under proper laboratory control, thromboemboli can 
be prevented by prophylactic anticoagulant therapy. 

Provided careful screening of patients is carried 
out, excluding those with accepted contraindications 
to anticoagulant therapy, serious hemorrhagic com- 
plications are few. Sevitt and Gallagher had 2 major 
complications in their control group, and 5 in the 
phenindione-treated group, with no deaths. Bottom- 
ley et al. reported a total incidence of bleeding of 
4.2 per cent but only 0.8 per cent of patients re- 
quired either transfusion or further medical treat- 
ment; in prophylactic therapy in 3,777 postoperative 
gynecologic patients, only 1 death was attributed to 
anticoagulant therapy. The apparent reluctance of 
many physicians to employ prophylactic anticoagu- 
lant therapy, even in high-risk patients, is probably 
due to excessive fears about hemorrhagic complica- 
tions and insufficient recognition of the effectiveness 
of anticoagulant therapy in venous thrombosis. As 
recently suggested, there is a potent but subtle ex- 
planation for this reluctance to employ a prophylactic 
therapy; it is not easy to employ a mode of therapy 
in which success cannot be recognized in the indi- 
vidual patient but in which a deleterious hemorrhagic 
complication of therapy is readily apparent. 

Therapy of Overt Pulmonary Embolism 

Heparin has been used in the treatment of venous 
thrombosis for nearly thirty years, and reports that 
such therapy reduced the number of deaths from 
pulmonary embolism go back to the late 1930's. 
Reporting on the early Swedish experience, Jorpes 
wrote that the results after anticoagulant therapy in 
venous thromboembolism were "as striking as any 
hitherto reported following the introduction of a 
specific therapy in medicine." Bauer has recently re- 
viewed his experience with heparin therapy for ven- 
ous thrombosis. Of 59 patients with pulmonary em- 
boli complicating venous thrombi, and treated with 
heparin, 2 died from complicating bronchopneu- 
monia whereas the remaining 57 patients survived. 
Many of these patients were in poor condition be- 
cause of massive embolism, and 10 had had repeat- 
ed attacks. However, it was not until I960 that Bar- 
ritt and lordan reported a study in which a concur- 
rent series was observed, assigning patients by ran- 



U.S. NAVY MEDICAL NEWS LETTER 



dom selection into treated and control groups. A 
total of 35 patients in whom the diagnosis of pulmon- 
ary embolism was made, and in whom there was no 
contraindication to anticoagulant therapy, were ad- 
mitted to the study. Of the 19 untreated cases 5 
died, and 5 others had nonfatal recurrences of em- 
bolism. The 1 death in the treated group was due to 
a combination of suppurative pneumonia and gas- 
trointestinal bleeding. At this point in the trial no 
further patients were admitted to the untreated 
group, but 38 others were taken into the treated 
group, making a total of 54. There was only 1 
further death, which was due to renal tubular ne- 
crosis from an adverse effect of the anticoagulant, 
phenindione. The form of therapy employed was 
10,000 units of heparin given intravenously every 
six hours for six doses, with concurrent oral admin- 
istration of a coumarin derivative (Nicoumalone), 
which was continued for fourteen days. In these 2 
series the mortality rate in patients with pulmonary 
embolism placed on anticoagulant therapy was 
about 4 per cent, although in both series the deaths 
were apparently not due to pulmonary emboli. In 
other studies the incidence of fatal pulmonary em- 
boli after anticoagulant therapy ranged from to 2.2 
per cent. In contrast, the mortality rates in 2 series 
in which the patients received no specific treatment 
were 26 per cent and 32 per cent, respectively. 

The optimum dose of heparin that should be given 
to a patient with an acute pulmonary embolus is 
unsettled. The minimum dose appears to be one that 
keeps the clotting time in excess of twice the control 
value at all times, for venous thrombi will not form 
or propagate experimentally under such conditions. 
However, the dose of heparin required to prolong 
the clotting time varies considerably, especially in 
the patients who have an acute thrombus. It is not 
without interest that the workers who have claimed 
the greatest success with heparin therapy have 
usually given at least 40,000 units of heparin per 
day during the initial therapy. Whether adequate 
heparin therapy for an acute embolus can also be 
given by the subcutaneous or the intramuscular 
route is as yet uncertain. There is some evidence 
that subcutaneous and intramuscular heparin ther- 
apy may occasionally be complicated by arterial em- 
boli. 

Pulmonary embolic disease due to recurrent 
showers of small emboli tends to have an insidious 
onset and leads to obliterative pulmonary hyperten- 
sion, owing to the gradual destruction of the pul- 
monary vascular bed by microscopic thromboem- 
boli. These patients are often post-partum women, 



in whom the only presenting symptoms may be 
dyspnea, fatigue and early signs of strain of the right 
side of the heart. In such cases, if the diagnosis is 
not made early, and anticoagulant therapy is not giv- 
en promptly, the pulmonary hypertension becomes 
irreversible, and death from intractable failure of the 
right side of the heart results in a period of months 
to years. A few cases have been reported in which 
this sequence appears to have been prevented by an- 
ticoagulant therapy. In 1 patient with established 
thromboembolic pulmonary hypertension, a marked 
fall in pulmonary-artery pressure followed eighteen 
months of anticoagulant therapy; five months after 
the cessation of therapy the signs of pulmonary hy- 
pertension reappeared. These signs again disap- 
peared when the anticoagulant therapy was reinsti- 
tuted. Despite encouraging case reports such as this 
one, the overall prognosis in patients with estab- 
lished obliterative pulmonary hypertension is poor, 
and in the series reported by Goodwin et al., 1 1 out 
of 19 patients died over a five-year period. However, 
as Goodwin pointed out, the failure of anticoagulant 
therapy in this group was probably due to late diag- 
nosis and treatment. 

Fibrinolytic Therapy 

Reports on the use of fibrinolytic agents in pul- 
monary embolism are beginning to appear. Israel 
et al. found that anticoagulant therapy combined 
with fibrinolytic therapy gave results that were 
superior to anticoagulant therapy alone. However, 
the study compared results on one service (antico- 
agulants) with results on another service (anticoagu- 
lants and fibrinolysin), which is a technic that does 
not allow separation of the effects of therapy from 
those of selection. For example, they found a 40 per 
cent mortality in the patients who were given anti- 
coagulant therapy alone, which is considerably in 
excess of that reported in most series. In 4 of their 
patients treated with fibrinolysin serum hepatitis 
subsequently developed. They concluded that treat- 
ment of pulmonary embolism by fibrinolysin was ad- 
visable only if the hazard of serum hepatitis could be 
eliminated. 

Sautter et al. have reported 2 cases of complete 
resolution of massive pulmonary thromboembolism, 
documented by arteriography. In neither was throm- 
bolytic therapy employed, and in 1 of the patients 
complete radiologic resolution occurred in twenty- 
five days. Fred and his co-workers have recently 
reported that in 4 patients with pulmonary emboli, 
but without pre-existing cardiorespiratory disease, 



U.S. NAVY MEDICAL NEWS LETTER 



repeat pulmonary angiograms nine to nineteen days 
later showed complete disappearance of the obstruc- 
tive lesions. No thrombolytic therapy was employed. 
These important observations represent a clinical 
confirmation of what has already been shown in 
dogs, in which autologous venous thromboemboli 
were found to be rapidly lysed. Although future de- 
velopments in this field will be observed with great 
interest it is likely that the therapeutic role of fibrin- 
olytic drugs in thromboembolism will not be easy to 
evaluate. It is apparent that the body possesses 
potent fibrinolytic mechanisms, and to assess the con- 
tribution of exogenous fibrinolytic drugs in the treat- 
ment of thromboembolic disorders will require care- 
ful prospective studies, with proper randomization 
of patients into control and treated groups. 

Surgical Management 

Over the years, the development of surgery for 
thromboembolic disease has ranged from superficial 
femoral ligation to common femoral ligation, thence 
to vena-cava ligation and finally to pulmonary em- 
bolectomy. The basic premise of venous ligation is 
that the great majority of emboli originate from the 
lower limbs and that by interruption of the main 
venous channels to the heart, the blood is forced to 
travel via smaller collateral channels. Large emboli 
are therefore prevented from traveling to the lungs 
from the legs, and death from massive pulmonary 
embolism is averted. It is apparent that there is a 
compelling simplicity to the surgical rationale for 
venous ligation. Similarly, if the pulmonary-outflow 
tract is occluded by a massive embolus, its prompt 
removal would obviously benefit the circulation. It 
will be argued, however, that the problem is not as 
clear cut as it appears. 

Venous Ligation 

The value of venous ligation in thromboembolism 
either prophylactically or therapeutically, is difficult 
to determine from the literature, largely because the 
studies reported have been retrospective, with no 
randomization of patients. The errors inherent in 
such types of study are well recognized, and the 
wide variations in reported results are probably due 
largely to biased sampling. For example, at 4 differ- 
ent hospitals in the same city, the mortality from 
pulmonary embolism after femoral-vein ligation has 
been reported as varying between 0.6 per cent and 
7.0 per cent. In the same series, the mortality in the 
patients who were treated with anticoagulant ther- 
apy varied from 2.1 per cent to 24 per cent. The 
difficulty in evaluating such results is compounded 



by the fact that in many patients who receive anti- 
coagulant therapy venous ligation is also performed. 

If clear distinctions are not drawn between the 
types of operation (such as superficial or common 
femoral ligation) and the type of anticoagulant ther- 
apy employed (such as heparin or a coumarin de- 
rivative) it becomes impossible to make valid com- 
parisons. Properly controlled clinical trials, with 
separation of patients into clearly defined treatment 
groups, and assignment of patients by random selec- 
tion, are essential before modes of therapy can be 
compared. Although it would obviously be unethical 
to withhold therapy from a patient with established 
pulmonary embolic disease, a prospective study of, 
for example, the comparative mortality and morbid- 
ity after vena-cava ligation and heparin therapy 
would be justified. 

The present emphasis in the surgical literature ap- 
pears to be on the superiority of vena-cava over fem- 
oral-vein ligation. This area has recently been well 
reviewed by Crane on the basis of his large expe- 
rience. In the absence of heart disease he found the 
in-hospital mortality to be 5 per cent with the latter 
and 2 per cent with the former. The incidence of 
postoperative morbidity was almost twice as high 
after femoral-vein ligation as after vena-cava liga- 
tion. However, in patients with heart disease the in- 
hospital mortality with either type of ligation varied 
from about 20 per cent in patients with failure of the 
left side of the heart to 40 to 50 per cent in those 
with right-sided failure. Crane concluded that vena- 
cava ligation had not been demonstrated to increase 
the patient salvage in late-stage congestive heart fail- 
ure. Krause et a!., reviewing their experience in 55 
cases of vena-cava ligation, claim that the operation 
had been 100 per cent effective in preventing recur- 
rent pulmonary embolism. They had 3 operative 
deaths and 7 late deaths due to other diseases. How- 
ever, 30 of their patients still living had been fol- 
lowed for less than two years. Mozes and his asso- 
ciates, in a study of 74 patients who had vena-cava 
ligation, reported 4 operative deaths and a further 4 
deaths from pulmonary emboli after ligation, giving 
a total failure rate of 1 1 per cent due to immediate 
mortality. These 3 papers, representing some of the 
recent larger series, suggest that vena-cava ligation 
can be performed with an operative mortality of ap- 
proximately 2 to 5 per cent in patients without heart 
failure. The late mortality ranges from a further 5 
per cent to 50 per cent, depending on the cardiac 
status of the patient. 

The reported morbidity after vena-cava ligation 
has varied greatly from series to series. In a large 



U.S. NAVY MEDICAL NEWS LETTER 



5 



series presented by Ochsner 45 out of 117 patients 
had no sequelae, 13 patients had mild edema, 28 
had edema controlled by bandaging, and 5 had 
edema controlled by bandaging and periodic eleva- 
tion of extremities. No patients had incapacitating 
sequelae. Similarly, Krause et al. described the mor- 
bidity as being "minimal." However, Mozes and his 
co-workers found severe sequelae in 12.5 per cent of 
patients, and Crane reported that 10 per cent of his 
patients had marked acute leg edema. Donaldson 
and his associates, on the other hand, reported that 
50 per cent of their patients had incapacitating late 
sequelae. Several surgeons have stated their belief 
that post-operative swelling results from pre-existing 
venous thrombosis, and not from the ligation of a 
major vein. This may well explain some of the wide 
variations in the reported incidence of sequelae. 

In an attempt to minimize the edema associated 
with complete interruption of the vena cava, modifi- 
cations have been introduced in which the lumen of 
the vessel is narrowed sufficiently to prevent the pas- 
sage of massive emboli, but not to prevent the flow 
of blood. Teflon clips and interrupted mattress su- 
tures (plication) have been the two main technics 
employed. Spencer et al. described 39 patients who 
had plication of the vena cava, with no pulmonary 
emboli within the first few months after operation. 
They commented that plication should not be done 
in patients with pulmonary hypertension from 
repeated small emboli, because such emboli could 
pass through the 3-mm channels constructed with 
plication. De Weese and Hunter reported their result 
in 24 patients in whom they placed a filter in the 
inferior vena cava. Seven of them died over a five- 
year period, although none apparently died from 
thromboembolism. However, the recognition of 
small pulmonary emboli at postmortem examination 
is difficult unless special technics are used, and these 
patients would be unlikely to die from large emboli, 
owing to the protective effect of the filter. Bergan et 
al. reported that of 10 patients on whom cavography 
was performed after plication, the vena cava was in 
fact occluded in 6. In their series vena-cava plication 
appeared to have no significant advantage over liga- 
tion. They made the important point that the clinical 
evaluation of a patient can be deceptive. Seven out 
of their 10 patients were assumed to have a patent 
vena cava before cavagrams, but only 3 had a patent 
vessel demonstrated by cavography. Moretz has 
reported that of 10 patients in whom a follow-up 
study was performed, the vena cava was not patent 
in 4. It seems probable, therefore, that in a high pro- 



portion of patients, plication of the inferior vena 
cava is converted into complete occlusion by 
trapped emboli. 

A study of the pathophysiology of pulmonary em- 
bolic disease leads one to question some of the ra- 
tionale behind venous ligation as a mode of therapy, 
at least regarding its long-term effectiveness. It may 
be taken as axiomatic that after venous ligation, the 
blood returns to the heart via collateral veins. Over 
a length of time these collateral channels enlarge in 
response to the increased volume of blood that they 
carry. For example, films obtained several months 
after vena-cava ligation demonstrate numerous en- 
larged collateral channels large enough to allow 
small emboli to reach the lungs. Even clinically rec- 
ognizable pulmonary emboli follow ligation of the 
inferior vena cava, and Gurewich and Thomas col- 
lected 8 such cases over a two-year period. In 2 of 
their patients the recurrence after caval ligation was 
documented by angiography, and in the others, the 
symptoms and signs, including characteristic radio- 
logic and electrocardiographic changes, were highly 
suggestive of pulmonary emboli. Davis et al. recently 
suggested that recurrent embolization from a cul-de- 
sac formed by poor location of the vena-cava liga- 
tion may also be responsible for some of the ap- 
parent failures. They recommend that ligation be 
performed just below the renal veins and that the 
cava be divided to avoid a cul-de-sac, where throm- 
bosis can occur, with subsequent embolization. 

It is now well recognized that multiple small em- 
boli can produce death from failure of the right side 
of the heart. Indeed, there is experimental evidence 
that acute cor pulmonale can be produced solely by 
platelet microemboli. If, as has been suggested, the 
spectrum of pulmonary embolic disease ranges from 
acute massive emboli through multiple small emboli 
to diffuse microemboli, it becomes apparent that 
only massive emboli are likely to be prevented by 
ligation. Of the total deaths from pulmonary emboli 
the percentage resulting from massive emboli is un- 
known. It seems likely, however, that more patients 
die from multiple small emboli than has been recog- 
nized in the past. In 34 patients whose deaths were 
attributed to pulmonary embolism, Smith et al. 
found multiple emboli in all cases. Post-mortem ar- 
teriography demonstrated approximately five times 
the number of emboli found by routine post-mortem 
examination, showing that small emboli can easily 
be missed on gross dissection of the lungs. Of partic- 
ular interest was their observation that emboli were 
most commonly found in muscular arteries, approxi- 



U.S. NAVY MEDICAL NEWS LETTER 



mately 85 per cent of which are less than 1 mm in 
internal diameter. Only 8 of the 34 patients had em- 
boli in the large elastic arteries. Although many of 
these small emboli may have "seeded" from larger 
emboli trapped in the right ventricle the implication 
of this work seems to be that a primary factor in 
pulmonary embolic disease is the occurrence of mul- 
tiple small emboli, which gradually occlude the pul- 
monary vascular bed. These emboli may reach the 
lungs by collateral channels even after the inferior 
vena cava has been tied. 

Pulmonary Embolectomy 

The operation of pulmonary embolectomy has re- 
cently been receiving increasing attention, and nu- 
merous case reports of successful embolectomies have 
appeared in the recent literature. Although success- 
ful results from the Trendelenburg operation are be- 
ing reported the technic of pulmonary embolectomy 
with cardiopulmonary bypass is now considered the 
operation of choice. Donaldson and his associates 
believe that at least one-fifth of the patients dying 
from massive embolism survive long enough to allow 
institution of a planned operative procedure. The 
crux of the issue, however, is the decision when to 
operate. Hampson et al. suggest that the correct time 
is when the patient is failing to respond to conserva- 
tive measures, and in their experience if the patient 
does not respond to oxygen, morphine and heparin 
within thirty minutes, recovery is unlikely. Hayward 
and Howqua, in reporting a successful Trendelen- 
burg operation, stress the point that the embolec- 
tomy should be regarded as an incident during the 
course of medical treatment for pulmonary embolism. 
and not as an alternative to this treatment. They 
believe that, after embolectomy, the patient must be 
assumed to be still suffering from pulmonary embolism 
and still in need of the medical treatment for it. A 
recent editorial suggested that a new period of more 
active therapy for massive pulmonary embolism is ar- 
riving. If this is so, perhaps it is permissible to raise 
certain questions, while the matter is still sub judice. 
As Donaldson and his co-workers noted, the greatest 
challenge lies in the decision to proceed with operative 
intervention in critically ill patients, some of whom 
will recover spontaneously. The challenge is particu- 
larly great since there is evidence that intravenous 
administration of herapin represents a highly effective 
mode of therapy in the patients who do not die 
immediately from massive pulmonary embolism. 
The only way to resolve such a problem is for a 
large general hospital, or group of hospitals, to un- 



dertake a prospective controlled trial of therapy, 
comparing the effects of pulmonary embolectomy 
with heparin therapy. The example of a recent co- 
operative prospective study of the role of surgery 
(portacaval shunt) in portal hypertension could well 
be followed. Such a study is not as unrealistic as it 
might at first appear, for Sautter has already report- 
ed 5 personally performed embolectomies. Despite 
the obvious difficulties, a controlled trial is needed 
before opinions become crystallized solely on the 
basis of personal experience. 

Acute Venous Thrombosis 

The treatment of acute venous thrombosis ("a- 
cute phlebitis") has recently been reviewed and will 
not be considered in detail here. However, certain 
aspects of the therapy of pulmonary embolism 
apply, pari passu, to venous thrombosis. The major 
hazard to patients with peripheral venous throm- 
bosis is pulmonary emboli, and it seems reasonable 
to conclude that patients in whom the diagnosis of 
venous thrombosis has been made should be consid- 
ered candidates for prophylactic therapy. A patient 
with overt thrombophlebitis is clearly in a "high- 
risk" category in relation to the possibility of embo- 
lism. The proved efficacy of anticoagulant therapy in 
preventing embolic complications of venous throm- 
bosis with minimal hazard of hemorrhage, indicates 
that this is the treatment of choice. If current con- 
cepts of the pathogenesis of venous thrombosis are 
correct it is also more physiologic to employ an 
agent that reduces systematic hypercoagulability 
without increasing local stasis. If this argument is 
followed further there seems to be little therapeutic 
rationale in separating superficial from deep venous 
thrombosis or thrombosis in the legs from throm- 
bosis in the thighs. If it is borne in mind that the 
clinical diagnosis of venous thrombosis is highly in- 
accurate any overt evidence for thrombosis suggests 
that the patient may be in a thrombotic state, with a 
propensity for forming thrombi at other sites. Al- 
though a patient may appear to have an acute super- 
ficial thrombophlebitis in the calf the presence of a 
concomitant silent deep venous thrombus cannot be 
excluded by clinical examination. Hafner et al. 
found that in 1 7 per cent of patients with the diag- 
nosis of superficial thrombophlebitis, at operation 
deep thrombophlebitis had in fact also developed. A 
further 2.3 per cent had evidence of pulmonary em- 
bolism. In this series of 133 patients, therefore, 1 in 
5 of those who appeared to have only superficial 



U.S. NAVY MEDICAL NEWS LETTER 



thrombophlebitis did in fact have a potentially lethal 
condition. It seems more logical to regard the pres- 
ence of thrombosis in an acute form at any site as 
an indication of a thrombotic state, which should, 
ipso facto, be treated with prophylactic anticoagu- 
lant therapy. The treatment prevents propagation of 
a thrombus, but more important is the fact that it is 
also prophylactic therapy for pulmonary embolism. 

Discussion 

It is apparent that no universal agreement exists 
on the proper management of pulmonary embolic 
disease. Many of the data supporting the various 
modes of therapy do not stand up to critical examin- 
ation. In particular, there are few data in which one 
mode of therapy has been concurrently compared 
with another, a proper comparison of relative effec- 
tiveness thus being made very difficult. Although re- 
cent experimental work has enlarged the under- 
standing of the pathogenesis of venous thrombosis, 
the extent to which these findings are applicable to 
man is still unclear. However, as Samuel Butler 
pointed out, "Life is the art of drawing sufficient 
conclusions from insufficient premises," and the fol- 
lowing general conclusions are offered in the belief 
that they represent a reasonable basis for treatment 
in the present state of knowledge. 

Convincing evidence exists that prophylactic anti- 
coagulant therapy should be employed in patients 
with illnesses in which there is a high incidence of 
thromboembolic complications. Patients with immo- 
bilizing fractures, burns, previous history of throm- 
boembolism and congestive heart failure fall into 
this category. In a particular patient the point at 
which the hazards of thromboemboli exceed the haz- 
ards of therapy can only be decided on the basis of 
good clinical judgment. However, it seems likely 
that many physicians have tended to underestimate 
the former and overestimate the latter. The treat- 
ment of choice for an acute pulmonary embolus is 
intravenous heparin therapy. The length of time that 
heparin should be administered is unclear. Barritt 
and Jordan gave only 6 doses and followed this by 
an orally administered drug for two weeks. Bauer 
gave intravenous heparin until the patient was fully 
mobilized. Others have recommended that heparin 
therapy be continued for a minimum of eight to ten 
days, which is the time required for firm adherence 
to the vein wall of experimentally produced bland 
thromboembolism. It seems reasonable to conclude, 
therefore, that heparin should be given at least until 



oral therapy has adequately depressed the prothrom- 
bin time. 

The indications for long-term anticoagulant ther- 
apy are not yet well established. Barker and Priestly 
reported a 30 per cent recurrence of pulmonary em- 
bolism in 381 patients who had had an initial pul- 
monary embolus and survived. In many cases it is 
clear that pulmonary embolism is a recurrent dis- 
ease, and it seems logical, therefore, that such pa- 
tients should be placed on anticoagulant therapy for 
an indefinite period. Patients who have thromboem- 
bolic obliterative pulmonary hypertension cannot 
afford to suffer further emboli, and should be placed 
on permanent anticoagulant therapy. However, in 
many patients the advisability of long-term therapy 
is more difficult to determine, for they have neither 
recurrent disease nor established pulmonary hyper- 
tension. Although it is clear that the minimal length 
of therapy is until the patient is fully mobile, the 
optimal length is uncertain. Nevertheless, there is a 
growing tendency to treat patients for six to twelve 
months, particularly if the emboli occur "sponta- 
neously." This practice is based on the clinical im- 
pression that pulmonary emboli are particularly apt 
to recur within this period. 

Venous ligation has a definite place in the therapy 
of pulmonary embolic disease, although the extent to 
which it should be employed is disputed. However, 
there is general agreement that in the patients in 
whom a contraindication to anticoagulant therapy 
exists, or in whom pulmonary emboli are occurring 
in the face of adequate anticoagulant therapy, vena- 
cava ligation is the treatment of choice. And yet pa- 
tients in whom emboli continue to form despite ade- 
quate heparin therapy, and who then have inferior 
vena-cava ligation, should also be placed back on 
heparin therapy after operation. It is doubtful 
whether femoral-vein ligation alone, either superfi- 
cial or common, gives adequate protection against 
either an initial or a recurrent pulmonary embolus. 
The patients who collapse with a massive pulmonary 
embolus, and who do not respond rapidly to conserv- 
ative measures, including immediate intravenous 
infusion of heparin, are candidates for a pulmonary 
embolectomy if the facilities are readily available. 
However, the evidence suggests that the great major- 
ity of patients suffering from massive pulmonary 
embolism either will die before any therapy can be 
administered or will respond to prompt and vigorous 
medical therapy. 

Finally, although the pathogenesis of pulmonary 
embolic disease has yet to be fully elucidated, and 



U.S. NAVY MEDICAL "NEWS LETTER 



although diagnosis still presents a great challenge, it 
is believed that the wider application of current 
knowledge, especially in the areas of prophylaxis, 



would do much to reduce the toll of the disease. — 
(The many references of this article can be seen in 
the original article in the New Eng J Med.) 



THE DIAGNOSIS AND TREATMENT OF 
WHIPPLE'S DISEASE 

Julian M, Ruffin MD and W. M. Roufait MD*.AmJ Digestive Diseases 
10(10): 887-891, October 1965. 



Since "intestinal lipodystrophy" was first de- 
scribed by Whipple' in 1907, many misconceptions 
concerning this remarkable disease have persisted, 
until recently. The name itself implied that the dis- 
ease was a disturbance of fat metabolism affecting 
primarily the small intestine. It was generally be- 
lieved that the disease was a rarity, that it could be 
diagnosed only by laparotomy or at autopsy, and 
that it was invariably fatal. According to recent 
reports, these beliefs would seem to be erroneous. 

Although Whipple himself recognized that the ma- 
terial in the macrophages would not stain as fat, his 
patient had large amounts of fat in the stool, and he 
assumed that the disease represented a disturbance 
of fat metabolism. We now know that this material, 
which gives the periodic acid-Schiff positive stain 
(PAS-positive) so characteristic of the disease, is a 
glycoprotein.- It has been known for some time that 
the disease is not confined to the intestine and adja- 
cent nodes. "Characteristic sickleform PAS-positive 
cytoplasmic particles have been demonstrated in mes- 
othelial cells of the pleural, peritoneal, pericardial, 
and synovial lining cells," and also in "the intestine, 
liver and mesenteric, and peripheral lymph 
nodes." *- s The disease may not be as rare as is 
generally thought, but merely unrecognized. The 
diagnosis can be made readily by peroral intestinal 
biopsy or even by peripheral lymph node biopsy in 
some cases; "' r certainly, it is not necessarily fatal. 

Under the electron microscope, the PAS-positive 
material appears as masses of gram-positive bacilli 
measuring 0.25 X 1 .Sfi.^" These structures disinte- 
grate under antibiotic therapy, but retain their stain- 
ing characteristics until they have disappeared alto- 
gether. While these bacteria appear to be invariably 
present in the untreated patient and in relapse, their 
etiologic relationship to the disease is yet to be es- 
tablished. To date the disease has not been repro- 



* Front the Department of Medicine, Duke University Medical Center, 
Durham, N.C. 

U.S. NAVY MEDICAL NEWS LETTER 



duced in the experimental animal nor has it been 
transmitted in man. 

Diagnosis 

Material 

Between 1936 and the present, 16 patients with 
Whipple's disease have been studied here; the cases 
of 15 have been reported previously. 7 * "-^ One pa- 
tient was a white female and one a Negro male; the 
remainder were white males. Their ages at the time 
of diagnosis ranged between 35 and 62 years. Before 
diagnosis, the patients had had symptoms other than 
arthralgia for 6 months to 4 years. In 10 of the 16 
cases, the disease was suspected clinically, and the 
diagnosis was established during life in all except 3. 
Nine of these patients are alive and well at the pres- 
ent time. 

Clinical Picture 

The patient is usually a middle-aged white male 
with a history of intermittent arthritis or arthralgia 
involving multiple joints over a period of years. How- 
ever, the actual illness is likely to start gradually 
with diarrhea; later, gross steatorrhea is accompa- 
nied by a marked weight loss and a rapid downhill 
course. Occasionally, there is no diarrhea and the 
illness may be accompanied by fever of varying de- 
gree. Under such circumstances, the picture is likely 
to remain unchanged until death unless altered by 
specific therapy. Determining the date of onset may 
be difficult, if not impossible. If the joint manifesta- 
tions are taken as a part of the disease, it has usually 
existed in mild form for years. Contrarily, if the 
diarrhea, progressive weight loss, and fever indicate 
the onset of the disease, it usually has been present 
for only a few months or years at most. There are 
no characteristic physical findings. Pigmentation 
and peripheral lymphadenopathy may be present 
and the spleen is palpable in a few cases. The dis- 

9 



ease should be suspected in any patient who has a 
longstanding history of arthritis and later loses a 
great deal of weight, with or without diarrhea. 

Constant Findings 

In all 16 patients, arthralgia or arthritis had been 
present for years. Marked weight loss, 20-100 lb 
had been noted in every case. Those patients who 
had had absorption studies all showed impairment of 
fat absorption. There were diffuse changes in the 
small bowel, especially in the duodenum and jeju- 
num, in those patients examined radiologically. 

The usual laboratory tests are of little value in 
establishing the diagnosis. The sine qua non is the 
demonstration of impaired absorption of fat. Radio- 
logic changes in the small bowel, although not diag- 
nostic, are highly suggestive of the disease. Actually, 
the diagnosis cannot be made without histologic 
study. The simplest method of obtaining a satisfac- 
tory specimen is by peroral intestinal biopsy. Find- 
ing the characteristic swollen villi filled with macro- 
phages and PAS-positive material establishes the 
diagnosis. 13 

Treatment 

For the first half of this century, once the diag- 
nosis had been established, the family was consoled 
and the patient sent home to die. In recent years, 
however, an appreciable number of recoveries fol- 
lowing various forms of therapy, especially adreno- 
corticoid and antibiotics had been reported. 1 (i - ,K How- 
ever, the widespread use of antibiotics in febrile 
illness and pre- and postoperative management makes 
it difficult to conclude that those patients reported to 
have recovered following ACTH administration alone 
did not receive antibiotics at some time during their 
illness. In an effort to solve this problem, the case 
histories of 10 patients who received antibiotics and 
steroids atone or in combination were reviewed. 1 ■"■ The 
3 who had received antibiotics alone and the 5 who 
had been given antibiotics and steroids all recovered. 
The 2 patients who died had been treated with ster- 
oids only. No patient relapsed while taking antibi- 
otics. Two had relapses during the administration of 
steroids only, but recovered after the addition of an- 
tibiotics. It was felt, therefore, that antibiotics rather 
than steroids were responsible for recovery in this 
group. 

Recommended Therapy 

AH patients should be hospitalized and treated in- 
tensively with 1 ,200,000 U of procaine penicillin G 
and 1 gm of streptomycin daily for 1 days to 2 



weeks. A broad-spectrum antibiotic, tetracycline, is 
then given by mouth in 1-gm doses daily for the 
next 10-12 months. 

Within days after institution of appropriate anti- 
biotic therapy, the patient experiences a sense of 
well-being; the appetite returns, the diarrhea ceases, 
the fever subsides, and a gradual gain in weight is 
observed. As in other diseases, clinical recovery may 
by months or years antedate histologic reversion to 
normal. The PAS-positive material may be present 
in considerable amounts in the villi as long as 2 
years after institution of therapy. 1 n Even though 
PAS-positive material is still present in the villi, the 
roentgenogram of the small bowel is likely to show 
reversion to normal within a few months, as is im- 
paired absorption of fat and other abnormal labora- 
tory findings. 

None of the patients who received therapy as out- 
lined has experienced a relapse during the period of 
follow-up, 7 months to 8 years. However, relapses 
have been observed in 4 patients who received ther- 
apy for 6 months or less; all recovered and remained 
well after more prolonged treatment. 

Summary 

1 . Whipple's disease probably is not as rare as is 
generally believed, but merely unrecognized. The 
PAS-positive material in the macrophages of the villi 
appears to be intact or disintegrated bacilli; how- 
ever, the etiology of the disease is yet to be estab- 
lished. 

2. Suspected clinically, Whipple's disease is diag- 
nosed on peroral small bowel biopsy. 

3. Intensive therapy with antibiotics should result 
in complete and permanent recovery. 

References 

1. Whipple, G. H. A hitherto undescribed disease characterized 
anatomically by deposits of fat and fatty acids in !he intestinal 
and mesenleric lymphatic tissues. Bull Johns Hopkins Hosn 18: 
382, 1907. 

2. Black-Schaffer, B. The tinctorial demonstration of glycoprotein 
in Whipple's disease. Proc Soc Exper Bioi & Med 72: 225, 1949. 

3. Upton, A. C. Histochemical investigation of mesenchymal lesions 
in Whipple's disease. Am J Clin Path 22: 755, 1952. 

4. Fisher, E. R., and Whitman, J. Whipple's disease: report of a 
case apparently cured and discussion Df the histochemical features. 
Cleveland Clin Quart 21: 213, 1954. 

5. Sieracki, J. C. Whipple's disease: observations on systemic 
involvement. 1. Cytologic observations. AMA Arch Path 66: 464, 

6. Lepore, M. J. Whipple's intestinal lipodystrophy. Am J Med 17: 
160, 1954. 

7. Chears. W. C. Jr, Smith, A. G., and Ruffin, J. M. The diagnosis 
of Whipple's disease by peripheral lymph node biopsy. Am J 
Med 27: 351, 1959. 

8. Yardiey, J. H., and Hendrix. T. R. Combined electron and light 
microscopy in Whipple's disease. Bull Johns Hopkins Hosp 
109: 80, 1961. 

9. Chears, W. C. and Ashworth, C. T. Electron microscopic study of 
the intestinal mucosa, in Whipple's disease. Gastroenterology 41: 

10. Kurtz, S. M., Davis, T. D., and Ruffin, J. M. Light and electron 
microscopic studies of Whipple's disease. Lab Invest II: 635, 
1962. 



10 



U.S. NAVY MEDICAL NEWS LETTER 



14. 



Hendrix, J. P., Black-Schaffer, B., Withers, R. W., and Handler, 
P. Whipple's intestinal lipodystrophy; report of four cases and 
discussion of possible pathogenic factors. AMA Arch Int Med 
85: 91, 1950. 

Hargrove, M. D. Jr., Verner, J. V. Jr., Patrick, R. L., and 
Ruffin, J, M. Whipple's disease without diarrhea: report of a 
ease diagnosed by intestinal lube biopsy. JAMA 173: 1125, 1960. 
Hargrove, M. D. Jr., Verner, J. V. Jr., Smith. A. G., Horswelt, 
R. R., and Ruffin, I. M. Whipple's disease: report of two 
cases with intestinal biopsy before and after treatment. Gastro- 
enterology 39: 619, I960. 

Chears, W. C. Jr., Hargrove, M. D, Jr., Verner, J. V. Jr., 
Smith, A. G„ and Ruffin, J. M. Whipple's disease: a review of 
twelve patients from one service. Am J Med 30: 226, 1961. 



Davis, T. D. Jr., McBee, J. W-, Borland, J, L,, Kurtz, S. M., and 
Ruffin, J, M, The effect of antibiotic and steroid therapy in 
Whipple's disease. Gastroenterology 44: 2, 1963. 
Gross, J. B., Wollaeger, E. E., Sauer, W. G-, Huezenga, K. A., 
Dahlin, D. C. and Power, M. H. Whipple's disease:, report of 
four cases including two in brothers with observations on path- 
ologic physiology, diagnosis, and treatment. Gastroenterology 36: 
65. 1959. 

England, M. T,, French, J. M., and Rawson, A. B. Antibiotic 
control of diarrhea in Whipple's disease. Gastroenterology 39: 
219, I960. 

Holt, P. R., Isselbacher, K. J., and Jones, C. M. The reversi- 
bility of Whipple's disease: report of a case with comments on 
the influence of corticosteroid therapy. New England J Med 
264: 1335, 1961. 



RETROILLUMINATION OF RETINAL VESSELS IN 
RETINAL EDEMA 



Marions K. Jack MD, Seattle, Washington* Am J of Ophth 60(4); 645-647, 

October 1965 



In three cases of retinal disease of unrelated etiol- 
ogy but with similar clinical findings, direct ophthal- 
moscopy revealed a significant illumination of the 
retinal, vessels. The presence of this phenomenon 
was highly correlated with retinal dysfunction and 
was felt to represent a diagnostic sign of serous 
retinal edema. 

The phenomenon was noted by direct ophthal- 
moscopy utilizing indirect illumination (proximal 
illumination) of retinal vessels, principally the arteri- 
oles. When the light beam of the direct ophthalmo- 
scope was directed at a point near a retinal arteriole, 
a striking luminance of the arteriole occurred. Nor- 
mally, a small- amount of indirect illumination of 
vessels can be elicited if the light source is directed 
so that the border of its beam is directly adjacent to 
the vessel. This is especially true in children. It can 
be demonstrated in adults around the disc where the 
nerve-fiber layer is thicker. Figure 1 demonstrates 
the ophthalmoscopic picture of the indirect arteri- 
olar light reflex. 

Each of the three cases presented here was char- 
acterized by the patient's subjective appreciation of 
visual loss, demonstrable scotomas and visualization 
of retinal edema associated with a prominent indi- 
rect arteriolar light reflex. 




Case Reports 



Case I 



Unilateral macular degeneration associated with 
Grade 4 arteriolarsclerosis 

A 62-year-old white man complained of an 
abrupt awareness of blurred vision in his right eye. 
Examination demonstrated vision to be 6/30 in the 



From the Valley Forge General Hospital, Phoenixville, Pennsylvania. 



Fig. 1 The indirect retinal vascular reflex is 
demonstrated by directing the beam of the 
ophthalmoscope at point (A) and observing 
the luminance of the adjacent vessel. 



involved eye and ophthalmoscopic examination re- 
vealed silverwire arteriolarsclerotic changes in the 
macular branch of the superior temporal branch of 
the retinal artery. Grade 2 arteriolarsclerosis was 
noted in the other vessels. There was an absence of 
the foveal reflex and a slight haziness of the retina 
superior to and including the macula. Central visual 
field testing with a 3-mm white target demonstrated 
a pie-shaped juxta macular scotoma whose apex 
joined the point of fixation and whose periphery ex- 
tended to the 15-degree isopter. A bright indirect 
vascular reflex was easily visualized. Following a 
week of bedrest, oral nicotinic acid and chymoral 
medications, there was a progressive improvement in 
vision to 6/12-3; a reduction in the scotoma to the 



U.S. NAVY MEDICAL NEWS LETTER 



11 



5-degree isopter and a disappearance of the indirect 
vascular reflex. At three weeks, fine pigmentary 
changes were observed at the macula. 

Case 2 

Blurred vision following desensitization with 

pollen extracts 

A 40-year-old woman had begun desensitization 
for chronic seasonal pollenosis. There were episodes 
of severe local reactions to the injections in the form 
of massive edema of the upper arm. Twenty-four 
hours following a subcutaneous pollen extract injec- 
tion, the patient became aware of a poorly defined 
blurred sensation in her left eye. Although her vision 
was not greatly disturbed, she was concerned and 
sought attention. Examination revealed vision to be 
6/7 in the symptomatic left eye. Visualization of the 
fundus revealed some minimal indistinctness of the 
superior retina. The ophthalmoscope revealed a 
bright indirect illumination of the retinal vessels in 
that area. Central visual field testing with a 3-mm 
white test target demonstrated a large scotoma bor- 
dering on the fixation area and extending to the 
20-degree isopter. 

The patient was observed daily, the scotoma 
eventually disappeared and the indirect vascular 
reflex was gone in eight days. 

Case 3 

Mulitple bilateral scotomas associated with stron gly 
positive toxoplasmosis serology and skin test 

This most unusual case of a 38-year-old Latin 
American man concerns progressive loss of central 
vision first in one eye and then in the other. The 
patient complained of central visual loss. Central as 
well as peripheral scotomas were found. Fundus ex- 
amination revealed a loss of the foveal reflex and an 
indistinctness to the posterior pole of the retina. 
Within two weeks a similar process appeared in the 
other eye. There were no focal chorioretinal lesions 
to indicate a specific site of disease in either eye. In 
the presence of a strongly positive skin test to toxo- 
plasmosis and positive hemagglutination serology 
1:1024 and following no improvement with a course 
of systemic steroids, he was treated with Daraprim 
and sulfadiazine for six weeks. His vision returned 
to 6/6 bilaterally in two weeks, when disappearance 
of the scotomas and of the prominent indirect vascu- 
lar reflex was also noted. Six weeks later fine punc- 
tate stippling of the maculas was observed. 



Discussion 

Serous retinal edema is a commonly made but 
poorly confirmed observation. It is pointed out that 
serous retinal edema may be present for a consider- 
able period before it is clinically recognized because 
of the similarity of the indices of refraction of the 
edema fluid and the retinal cellular elements. 1 

When disease results in capillary injury to the ex- 
tent that there is escape of albumin and fibrinogen 
into the retina as well as cellular breakdown, exu- 
dates are formed that are easily visible because of 
their striking white and dull gray-white color. The 
edema exudates of commotio retinae and Purtscher's 
retinopathy are of this type." The watery edema of 
angiospastic retinopathy is different. Even at the 
macula where edema is most easily recognized, the 
changes are more subtle and subjective. The color of 
the edematous area reveals very little change from 
normal. There is a characteristic circular or oval 
light reflex. 3 In general, serous retinal edema is diffi- 
cult to detect elsewhere. The retina generally ap- 
pears thicker and more opaque. There is a granular 
appearance with shimmering and irregular light 
reflexes. These findings are accentuated in red-free 
light. ' At times the minute and parallel nerve fibers 
are accentuated and thrown into relief in direct illu- 
mination. Fundus slitlamp examination, as demon- 
strated by Pischel, at times demonstrates relucency 
from the inner retinal layers as well as the outer."' 

Indirect illumination, ordinarily reserved for slit- 
lamp biomicroscopy, is produced by directing a 



f 


^/ st 




£~~_ jaJHj 






SHn 



Fig. 2 Indirect illumination of the retina is ac- 
complished by observing the illuminated area 
adjacent to the direct beam of the ophthalmo- 
scope. Illumination of this adjacent area occurs 
by scattered and internally reflected light rays. 



12 



U.S. NAVY MEDICAL NEWS LETTER 



beam of light on semitransparent tissues, such as the 
iris. The observer directs his attention adjacent to 
the direct area of illumination. In these adjacent 
areas structures not readily seen are illuminated by 
scattered light and internally reflected light (fig. 2). 

Scheie ' has pointed out that nascent prolifera- 
tions of the pigment epithelium can often be vis- 
ualized by this method. He also utilizes indirect 
illumination of the optic disc to evaluate suspected 
pallor of not readily evident optic atrophy. 

Indirect illumination of retinal arterioles reverses 
the light pattern seen by direct illumination, which 
produces a centrally located "light reflex" from spec- 
ular reflection. With indirect illumination, the cen- 
tral zone of the vessel is dark (fig. 1). Transmission 
of light through a fluid-filled tubular structure is sim- 
ilar to that which occurs when light passes through 
two strong plus cylinders axis to axis. The image of 
the light source becomes a focal line of light whose 
axis corresponds to that of the cylinders. 

When a beam of light is reflected from the cho- 
roid through a vessel, a majority of the reflected rays 
are transmitted through the vessel. They are not vis- 
ible to the observer at the light source. What the 
observer does observe is only the internally reflected 
light, which appears as the two bright outer bands of 
the vessel in Figure 1 . When the reflected rays strike 
the inner wall of the vessel tangentially so as to over- 
come the critical angle of reflection, there is internal 
reflection and this light will be appreciated as the 
soft red incandescence of the vessels (fig. 3). 

A probable explanation for the intensified indirect 
vascular reflex in serous retinal edema is that, when 
the vessel is in close apposition to the reflected sur- 
face, a relatively small per cent of the light is avail- 
able for internal reflection. Within certain limits 
when the vessel is farther away from the reflecting 
surface more light is available for internal reflection. 




Fig. 3. Diagram to demonstrate the effect of 
indirect light on a retinal vessel. Here one ray 
is transmitted through the vessel and another is 
internally reflected. 

Summary 

Three diverse cases of retinal disease character- 
ized by retinal edema, scotomas and transient objec- 
tive and subjective visual loss are presented. 

Indirect illumination of retinal arterioles in these 
cases produced a vascular illumination that was felt 
to represent a diagnostic sign of serous retinal 
edema. 

References 

1 Hogan, M. J. and Zimmerman, L. E. (editors) : Ophthalmic 
Pathology. Philadelphia, Saunders, 1962, ed. 2., p. 504. 

2 Elwin H ; Diseases of the Retina, New York, Blakiston, ed. 2, 
pp, 41, 167, 172. 

3. Ibid, p. 63. 

4 Duke-Elder, S. : Textbook of Ophthalmology: Volume III. 
Diseases of the Inner Eye. St. Louis, Mosby, 1945, pp. 2588-2592. 

5 Pischel, D. K.: Slitlamp examination of the fundus. Arch Ophth 
60: 811-814, November 1958. 

6 Berliner, M. L. : Biomicroscopy of 1lte Eye. New York, Hoeber, 
1949 1: 105-108. 

7. Scheie, H. G. : Personal Communication. 



FROM THE NOTE BOOK 



SURGEON'S TOOL 

The Defense Department has approved a new 
orthopedic drill which is expected to be used in Ser- 
vice hospitals in the U.S. and overseas, including 
Vietnam. Tested at Wilford Hall USAF Hospital, 
Lackland AFB, San Antonio, the cordless electric 
drill was conceived by Dr. David B. Horner, a prom- 



inent orthopedic surgeon with an extensive prac- 
tice in the Los Angeles area. The Mira Corporation, 
Los Angeles, developed and manufactures the in- 
strument which carries Dr. Horner's name. 

The Horner Surgical Drill, used in bone repair, is 
powered by a rechargeable, high-energy nickel cad- 
mium battery which does away with electric wires, 



U.S. NAVY MEDICAL NEWS LETTER 



13 



connections, foot switches, air hoses and other ancil- 
lary equipment necessary with other power drills. A 
particular advantage for military field and disaster 
use is that the Horner Drill can be used in areas 
remote from electric power receptacles because its 
battery stores more electric energy than is required 
to power the most extensive surgical drilling proce- 
dures. 

The drill, with its power pack, weighs four 
pounds. The power pack will last from three to five 
years. 

PHENOTH1AZINES 

Skin-Eye Syndrome 

Incidence: Observations were made on 650 men- 
tal patients who were receiving psychotherapeutic 
drugs. Many of the patients had received several 
courses of various phenothiazines, particularly Tho- 
razine (chlorpromazine). None of the patients 
showed evidence of skin photosensitivity. However, 
103 patients manifested a marked tendency to sun- 
burn, 1 8 developed marked suntanning resulting in a 
true brown or bronze color, and 97 acquired a gray 
or violaceous pigmentation. Slitlamp examinations 
revealed opacities in the lens and cornea of 33 pa- 
tients and in the lens alone in 145. Thus more than 
25 per cent had eye changes. All but two patients 
had received Thorazine at one time or another. 
Duration of Thorazine therapy ranged from 2 weeks 
to 10 years. The drug had been given in maxi- 
mum daily doses of 25 to 1500 mg. However, the 
vast majority of patients had received 400 mg. Tho- 
razine daily for more than two years. Although Tho- 
razine is most often responsible for lens and corneal 
changes, other phenothiazines are also capable of 
producing such complications. There is some indica- 
tion that phenothiazine-induced lens and corneal 
changes are irreversible. — Barsa et al. (Orangeburg, 
N. Y.), Am J Psychiat 122: 331, Sept 1965. [For 
additional information see Clin-Alert No. 63, 1962; 
Clin- Alert No. 307, 1963; Clin-Alert No. 69, 87, 
137, 164, 180, 243, & 296, 1964; Clin-Alert No. 
43, 53 &75, 1965.] 

Specialists Opinion: Two ophthalmologists and 
one psychiatrist joined in this communication. Pa- 
tients who show skin pigmentation as a result of 
treatment with phenothiazines often develop granu- 
lar deposits in the lens and cornea. High-dosage 
patients may develop such eye changes in the ab- 
sence of skin changes. The phenothiazine-induced 
skin-eye syndrome should not be confused with that 
of retinal changes induced by Mellaril (thioridazine) 
the two differ radically in onset and pathology. — 



Brill, Scheie & DeLong, Am J Psychiat 122: 326, 
September 1965. Republished from CLIN-ALERT 
No. 270, October 21, 1965, by permission of 
Science Editors, Inc. 

VETERANS ADMINISTRATION MEETING 

The Veterans Administration will hold a surgical 
meeting March 21-22, 1966 at the Boca Raton Ho- 
tel, Boca Raton, Florida. Navy Surgeons are invited 
to attend as guests. Topics on the program include 
head and neck surgery, esophageal and pulmonary 
surgery, surgery of the endocrines and wound infec- 
tions. 

SYMPOSIUM ON CURRENT SURGICAL 
PRACTICES 

A symposium on current surgical practices will be 
held at Walter Reed General Hospital on Monday, 
Tuesday and Wednesday, 4, 5, and 6 April 1966, as 
announced in DA circular 350-22 dated 23 April 
1965, titled "Education and Training." The Surgeon 
General of the Army has given his strong support to 
this seminar. An outstanding program is being ar- 
ranged and will include recent advances in the fields 
of general surgery procedures and techniques. Sever- 
al civilian surgeons of national prominence are in- 
cluded on the program. 

You are urged to make application for presenta- 
tion of papers. Presentations will be limited to 15 
minutes with few exceptions. Case reports will also 
be accepted, limited to 5 minutes. Submit title of 
your paper, together with an abstract of not more 
than 50 words, and time desired for presentation, to 
Colonel C. W. Hughes MC USA, Chief, Department 
of Surgery, Walter Reed General Hospital, Walter 
Reed Army Medical Center, Washington, D.C. 
20012, with a copy to BuMed, not later than 1 Jan- 
uary 1966. 

The Symposium is open to surgeons of the Army, 
Air Force, Navy, Veterans Administration, and also 
civilians, particularly from the Reserve Corps and 
National Guard. All are invited and encouraged to 
attend. Social events will include the wives. There 
will be a "get-acquainted" cocktail-buffet on Sunday 
evening, 3 April, at the Walter Reed Army Medical 
Center Officers' Club. 

NAVAL MEDICAL RESEARCH REPORTS 

U.S. Naval School of Aviation Medicine, Naval Avi- 
ation Medical Center, Pensacola, Fla. 
1 . A Data Processing System for the Ballistocardio- 
gram: MR 005. 13-7004 Subtask 6 Report No. 
12, February 1965. 



14 



U.S. NAVY MEDICAL NEWS LETTER 



2. The Effects of Visual Deprivation on Adaptation 
to a Rotating Environment: MR 005. 13-6001 
Subtask 1 Report No. 106, March 1965. 

3. Correlational Analysis of Qualitative Data: MR 
005. 13-3003 Subtask 1 Report No. 42, May 
1965. 

4. The K-Coefficient, A Pearson-Type Substitute 
for the Contingency Coefficient: MR 005. 
13-3003 Subtask 1 Report No, 43, May 1965. 

5. A Study of Statement Attractiveness Indices Ob- 
tained Under Personal and Social Orientations: 
MF 022. 01. 02-5001 Subtask 1 Report No. 44, 
July 1965. 

6. A Study of the Interpersonal Values Reported 
by Naval Aviation Pre-Flight Students: MF 
022. 01. 02-5001 Subtask 1 Report No. 45, July 
1965. 

7. Airsickness in Student Aviators: MR 005. 
13-6001 Subtask 6 Report No. 1, July 1965. 

8. The Relationship Between Past History of Mo- 



tion Sickness and Attrition From Flight Train- 
ing: MR 005. 13-3003 Subtask 10 Report No. 
8, June 1965. 

U.S. Naval Radiological Defense Laboratory, San 
Francisco, Calif. 

1 . Presence of Donor Specific Globulins in Sera of 
Allogeneic Mouse Radiation Chimeras: MR 
005. 08-5200, February 1964. 

2. Additive Inhibitory Effect of Sublethal X-Ra- 
diation Plus Allogeneic Lymphoid Cells on 
Transplanted Mouse Leukemia: MR 005. 
08-1200 Subtask 2, July 1965. 

3. Decreased Radiation Mortality in Dogs Treated 
with Typhoid-Paratyphoid Vaccine: MR 005. 
08-5201 Subtask 1, July 1965. 

4. Temperature Adaptation of the Growth and Di- 
vision Process of Tetrahymena Pyriformis. I. 
Adaptation Phase: MR 005. 08-1200 Subtask 9, 
July 1965. 



DENTAL SECTION 



Naval Dental Research Reports 

To complete the series of Navy presentations at 
the 43rd General Meeting of the International Asso- 
ciation for Dental Research, the last three of fifteen 
abstracts, concerning the Naval Dental Corps' intra- 
mural research program, are reproduced with the 
permission of the Editor, J D Res. LCDR J. P. 
Quinn MSC USN (B.S. Bacteriology), has 15 years 
experience in U.S. Navy Preventive Medicine, and at 
the U.S. Naval Medical Research Unit #1. He 
reported for duty at the Dental Research Facility, 
U.S.NT.C. Great Lakes in 1963. LCDR W. R. Cot- 
ton DC USN (MS, Microanatomy), LCDR W. J. 
Gorman DC USN and J. R. Lamb DT3 USN con- 
ducted their study at the Naval Medical Research 
Institute. LCDR Cotton is currently stationed at 
NMRI, and LCDR Gorman is in a Periodontics res- 
idency at the U.S. Naval Station, Treasure Island. 
The other authors' scientific backgrounds were cited 
in previous issues of this series. 

A RELATIONSHIP OF ANTIBACTERIAL 

ACTIVITY AND THE TOTAL SOLIDS 

CONTENT OF PAROTID SALIVA TO 

CARIES DEVELOPMENT 

J. P. Quinn and I. L. Shklair, Dental Research 
Facility, Great Lakes, Illinois. 

Nineteen naval recruits with a negative history of 
dental caries were studied during their first year of 



service. The ten recruits who developed lesions with- 
in the year and the nine who remained caries-free 
were compared relative to parotid saliva flow rate, 
its total solids content and its inhibition of Lactoba- 
cillus arabinosus ATTC #8014. There was no signif- 
icant difference in the degree of bacterial inhibition 
exhibited by the parotid saliva of the caries group 
and the caries-free group when measured by the 
two-fold serial dilution of lyophilized parotid saliva 
in Rogosa Broth. Calculation made of the milligrams 
per milliliter total solids of parotid saliva in the high- 
est dilution exhibiting no growth after twenty-four 
hours incubation indicated that the parotid saliva of 
the caries group contained essentially the same 
amount of inhibitory substance as the parotid saliva 
of the caries-free group. There was no significant dif- 
ference in the amount of solids secreted per milli- 
liter between the caries group and the caries-free 
group, however, the milligrams total solids per min- 
ute flow rate was seventy per cent greater for the 
caries-free group. 

PULP RESPONSE TO CAVITY 
DRYING IN RAT TEETH 

W. R. Cotton, W. J. Gorman and J. R. Lamb, 
Naval Medical Research Institute, Bethesda, Md. 

The immediate response of the pulp was evaluat- 
ed following drying of a cavity by a stream of tem- 
perate air for 5 minutes. Thirty-five maxillary first 



U.S. NAVY MEDICAL NEWS LETTER 



15 



molar teeth, 15 control and 20 experimental, were 
used. All cavity preparations were made under air- 
water spray with a wire-twist drill revolving at 1300 
± 40 rpm. All animals were sacrificed immediately 
upon completion of a test and control cavity in each 
rat. All 20 air-dried cavities showed odontoblast nu- 
clei displacement into the dentinal tubules. Thirteen 
of 1 5 non-air-dried cavities did not show nuclei dis- 
placement into the tubules. This would seem to indi- 
cate that one immediate response of the pulp to the 
air-stream was displacement of the odontoblast nu- 
clei into the dentinal tubules. Within the dentinal tu- 
bules of the experimental teeth, vacuoles were seen 
within the displaced nuclei. These may be degenera- 
tive changes. Increased number of depth of dis- 
placed nuclei occurred in tubules associated with the 
cavity margin, i. e., marginal displacement, in 9 of 
22 teeth which had ectopic nuclei. A significant (P 
< 0.01) correlation was found between the direct 
measurement of the cavity depth and both number 
(r = 0.589) and depth (r = 0.585) of nuclei dis- 
placement into the dentinal tubules. The tubular 
measurement of remaining dentin was significantly 
correlated to the number (r = -0.556, P < 0.02) 
and depth (r = -0.456, P < 0.05) of nuclei dis- 
placement. The direct measurement of remaining 
dentin was not significantly correlated to the number 
(r = -0.403, P > 0.05) and depth (r = 
-0.377, P > 0.10) of nuclei displacement. 

A SUGGESTION THAT COLLAGEN IS A 

THIRD CLASS OF PROTEIN 

WITH REGARD TO ITS LOW 

TEMPERATURE LUMINESCENCE 

K. C. Hoerman, S. A. Mancewicz and A. Y, 

Balekjian, Naval Medical Research 

Institute, Bethesda, Maryland. 

Total emissivity of powdered dentin collagen at 
89° K following irradiation with ultraviolet light at 
270 mju. revealed fluroescence maxima at 308 and 
395 m/x while phosphorescence occurred in a wide 
band whose maximum was at 420 m/i. The singlet- 
triplet transition in this tissue was related to the 308 
— 420 m/i intercombination leaving the fluorescence 
at 395 m,u without a detectable triplet state emis- 
sion. Diminished photomultiplier response at higher 
wavelengths could account for this. Normal acid-ex- 
tracted rat skin collagen had a single fluorescence 
maximum at 300 mp. with phosphorescence at 
395 m/i. It was implied from these data that an 
impurity secondary activation site existed in den- 
tin collagen. A comparative study was under- 
taken using as models RNase (phenylalanine -» tyro- 



sine emission), lysozyme and human serum albumin 
(phenylalanine -> tyrosine -> tryptophan emis- 
sion). The shape of the total emission curves and 
their maxima suggested that collagen dissipates ab- 
sorbed energy from a third order of luminescent cen- 
ter^). 

TREATMENT OF LARGE CYSTS OF THE 

JAWS IN CONSIDERATION OF 

POTENTIAL NEOPLASIA 

R. Weinstein, J Oral Surg 23(6): 489-496, 
September 1965. 

The author discusses the different methods of 
treating large cysts of the jaw. The two conservative 
approaches (1) the Partch or marsupialization oper- 
ation and (2) the tube technic are described, as well 
as complete enucleation. The objection to the mar- 
supialization and tube technic is that the patient is 
denied a complete microscopic examination. Such 
microscopic examinations have become more impor- 
tant with the increasing number of reports of neo- 
plastic development in the walls of cysts. Objections 
to enucleation revolve around the possibility of frac- 
ture or injury to adjacent or associated structures. 

The author then presents three cases treated by 
enucleation with primary wound closure. Results 
were satisfactory with no untoward effects, and the 
microscopic findings in two of the three patients 
gave ample justification for the method of treatment. 
In all three cases the clinical diagnosis was dentiger- 
ous cyst. Microscopic examination in just one case 
revealed merely a dentigerous cyst. In the second 
case the pathologist's diagnosis was dentigerous cyst 
with mural ameloblastoma arising from the second 
molar. The third case was a dentigerous cyst with 
ameloblastoma arising from the first molar. 

The author then reviews the literature describing 
the many reported cases of ameloblastomatous, 
adenoma-like and carcinomatous changes in the walls 
of these cysts. With a clinical diagnosis of dentiger- 
ous cyst, the surgeon who elects a marsupialization 
or tube technic must recognize the possibility that he 
is allowing a neoplasm to grow while he is waiting 
for the cyst to shrink or for the defect to fill in. 
Complete enucleation permits complete microscopic 
examination; and early diagnosis of neoplasm per- 
mits optimal treatment. (Abstracted by: CDR H. S. 
Kramer, Jr., DC USN, U.S. Naval Hospital, Chel- 
sea, Massachusetts.) 

DISEASES OF THE TEETH IN 1578 

One of the earliest known doctoral dissertations 
devoted to dentistry is that of Peter Monau, written 



16 



U.S. NAVY MEDICAL NEWS LETTER 



in 1578. The thesis "De Dentium Affectibus" was 
presented to the faculty at Basel on February 20, 
1578. Monau had studied at Wittenberg, Heidelberg 
and Padua before coming to Basel. 

Monau was born on April 9, 1551, the son of a 
patrician family of Breslau, and died while serving 
as physician to Kaiser Rudolph II in Prague on May 
12, 1588. 

Monau said that the tooth was hard at its func- 
tional surfaces, and softer at the roots. He found no 
nerves in teeth and described the periosteum as the 
most sensitive region. In addition to their principal 
masticatory function, Monau said that teeth aided in 
speech. Monau believed that certain diseases of 
teeth were inherited; he ascribed decay to ingestion 
of food too hot, too cold or too hard. He first de- 
scribed what is today recognized as pulpal polyps. 



For pain, Monau prescribed narcotics and local 
application of opium. Opium was to be applied in 
the form of a mouthwash or dissolved in milk, oil or 
wine. Monau cautioned against frequent intake of 
sweets because, he said, the teeth blackened and be- 
came susceptible to decay. He suggested frequent 
cleaning with toothpicks of wood rather than metal. 

Although many of Monau's comments and 
descriptions have long since been modified or dis- 
carded, when viewed against knowledge in the six- 
teenth century, the dissertation represented an excel- 
lent review and discussion. (Lorber, Curt Gerhard. 
Universitatsstrasse 10, Heidelberg 69, Germany. 
Peter Monau's Dokotordissertation Uber Erkran- 
kungen der Zahne aus dem Jahre 1578. Zahnarztl. 
Mitt. 53:764-765, Sept 1„ 1963, Dental Abs 10(7): 
426, July 1965. Copyright by the American Dental 
Association. Reprinted by permission.) 



PERSONNEL AND PROFESSIONAL NOTES 



NAVY EXCHANGES COOPERATE IN PRE- 
VENTIVE DENTISTRY PROGRAM 7 The Com- 
manding Officer, U.S. Navy Ship's Store Office, 
Brooklyn, New York recently distributed a notice to 
all activities operating Navy Exchanges requesting 
that they display signs promoting the use of stannous 
fluoride dentifrices. A sample sign was enclosed 
carrying the following message: 

Receivers of 

NAVY TOOTH DECAY 

PREVENTIVE TREATMENTS 

Are reminded that only 

STANNOUS FLUORIDE TOOTHPASTES 

INSURE FULL BENEFITS 

of the program 

The notice encouraged display of a sign in each 
area where dentifrices are sold for approximately 
one week out of each month. It was considered that 
signs of this nature would have a greater impact on 
customers if they were displayed intermittently 
rather than on a permanent basis. 

RED CROSS VOLUNTEER DENTAL CLINIC 
ASSISTANTS. Programs for Red Cross Volunteer 
Dental Clinic~Assistants in Armed Forces dental fa- 
cilities have been developed in conjunction with the 
national Headquarters, American National Red 
Cross. Pilot studies in naval activities have been 



highly successful. The ladies may perform as clerk- 
receptionists or as chairside assistants, depending on 
their level of training. This program is believed espe- 
cially appropriate and desirable at foreign shore and 
at CONUS activities which have been designated re- 
mote for dependent dental care. Many dependent la- 
dies seem to volunteer for this program because it 
gives them the satisfaction of contributing to the oral 
health and welfare of their own families. Others vol- 
unteer in part because it gives them opportunity to 
gain experience which will be useful in gaining em- 
ployment as a dental assistant to a private practi- 
tioner, in the area of her husband's next duty 
station. Dental officers may obtain additional infor- 
mation by a letter addressed to the Chief, Bureau of 
Medicine and Surgery (Attention Code 611). 

DENTAL OFFICER PRESENTATIONS. CAPT 

KT"cTHoerman DC USN, Head, Biochemistry Divi- 
sion, Dental Research Department, NMRI, partici- 
pated in the Seminars on Connective Tissues, 10-16 
October, Rheumatism Research Unit, University of 
Vermont, College of Medicine, Burlington, Ver- 
mont. He discussed "Molecular Luminescent Phe- 
nomena in Normal and Lathyritic Rat Skin Colla- 
gen." CAPT Hoerman recently relieved CAPT H. W. 
Lyon as Head, Research Branch, Dental Division, 
Bureau of Medicine and Surgery, and Dental Proj- 
ects Officer, Medicine and Dentistry Branch, Office 
of Naval Research. 



U.S. NAVY MEDICAL NEWS LETTER 



17 



CAPT P. J. Boyne DC USN, Director, Dental 
Research Department, NMRI, lectured on "Re- 
search in Oral Surgery," at the Surgical Seminar, 
Georgetown University, Washington, D. C, on 30 
September 1965. 

LCDR W. R. Cotton DC USN, Dental Research 
Department, NMRI, was a guest of the University of 



Alabama, School of Dentistry at the "Workshop on 
the Biology of the Dental Pulp Organ," 28 Sep- 
tember to 1 October 1965. Dr. Cotton presented a 
paper entitled, "New Techniques and Their Applica- 
tion to the Study of Pulp Tissue: Pulp Response to 
Cavity Preparation as Studied by the Method of 
Thymidine-H 3 Autoradiography." 



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PREVENTIVE MEDICINE SECTION 

VARIABLE EPIDEMIOLOGY OF STREPTOCOCCAL DISEASE AND THE 
CHANGING PATTERN OF RHEUMATIC FEVER 

G. H. Stollerman, A. C. Siegel, E. E. Johnson, Modern Concepts of Cardiovascular 
Disease 34(10): 45-48, Oct 1965. 



Decline in Overt Rheumatic Fever 

It is extremely difficult to determine accurately 
the incidence of acute rheumatic fever in large civil- 
ian populations. Few studies are available to sup- 
port with convincing data the impression of many 
clinicians that rheumatic fever is becoming less fre- 
quent and severe in North America and Europe. 
Mortality statistics reveal a striking decline in deaths 
due to acute rheumatic fever, STAMLER, 1962. In 
many cities of the United States, convalescent hospi- 
tals and homes for children with rheumatic fever 
have closed their doors or changed their admission 
poiicies to include patients with other related dis- 
eases. Some large pediatric hospitals which once 
reserved a special section of their medical wards for 
rheumatic fever patients now distribute the sporadic 
rheumatic case load among the general medical 
beds. 

It is becoming more difficult to find cases of Syd- 

18 



enham's chorea, and fulminating, fatal rheumatic 
pancarditis has become relatively rare. In many 
North American clinics, the school-age child with a 
huge heart, bulging precordium and greatly congest- 
ed liver is now more likely to have congenital heart 
disease than advanced rheumatic heart disease. A 
recent large-scale survey has shown that congenital 
heart disease is at least as common as rheumatic 
heart disease in the elementary school population, 
Miller, et al, 1962. 

Change in Streptococcal Epidemiology 

If there has been a decline in the incidence and 
severity of rheumatic fever, one might expect this to 
be related to a change in the epidemiology of strep- 
tococcal disease. Although there has been a marked 
decline in epidemic streptococcal sore throat and 
scarlet fever, group A streptococci have remained 
ubiquitous in school children's throats. Wherever ex- 

U.S. NAVY MEDICAL NEWS LETTER 



tensive throat culturing has been made, it has been 
possible to isolate these organisms in approximately 
40% of patients in this age group during the course 
of the school year, although the rate varies greatly in 
any given season, year, population, or geographical 
location. The prevalence of throat cultures positive 
for group A streptococci in some populations in 
which little rheumatic fever has been found has 
caused surprise and confusion. Some confusion 
stems from a lack of appreciation of the difficulties 
in distinguishing among (a) streptococcal and viral 
infection on clinical grounds alone, (b) carriers of 
group A streptococci and those actually infected, 
and (c) the severity of the streptococcal disease 
measured, not by clinical symptoms alone, but by 
other significant parameters, such as the magnitude 
of the immune response and the duration of conva- 
lescent carriage of the infecting organism. The latter 
two features of streptococcal infection have been 
shown to be related most closely to the attack rate 
of rheumatic fever, RAMMELKAMP, 1958, STET- 
SON, 1954. 

The magnitude of the immune response and the 
duration for which organisms persist in the throat 
during convalescence are related to the virulence of 
the streptococcal strain causing the infection. The 
two most important factors related to virulence of 
group A streptococci are the type-specific M protein 
surface antigen and the capsule of hyaluronic acid, 
both substances which confer upon the strepto- 
coccus the property of marked resistance to phago- 
cytosis, LANCEF1ELD, 1962. 

In military epidemics of streptococcal pharyngitis, 
more than 90% of the group A strains isolated from 
patients with exudative pharyngitis may be typablc 
with specific anti-M protein antisera, and usually 
one type predominates. Furthermore, such predom- 
inant, epidemic types are often richly encapsulated 
and may grow on solid media as large, mucoid col- 
onies. In untreated patients, such strains may persist 
in the throat for as long as 4 weeks in 80% of indi- 
viduals, and 85 to 90% of the individuals thus in- 
fected may show a vigorous response in antistrepto- 
lysin O, or other streptococcal antibodies. 

The relative mildness of the sporadic streptococ- 
cal disease which may be encountered in a large met- 
ropolitan population of school children from a rela- 
tively low socioeconomic group is demonstrated by 
recent studies in Chicago, S1EGEL, et al, 1961. In 
patients with pharyngitis associated with a throat 
culture positive for beta-hemolytic streptococci, 
85% harbored strains belonging to group A, but in 



less than half of these were the organisms typable 
with anti-M serum and in only half was the illness 
associated with an increase in antistreptolysin O 
titer. Furthermore, the magnitude of the antibody 
responses was considerably less than that observed 
in cases of exudative pharyngitis in military popula- 
tions. 

Clinically, of those patients with pharyngitis who 
had group A streptococci in their throats, only 40% 
had pharyngeal exudate, 30% had fever greater 
than 38.2C (101F) and only 16% had a white 
blood cell count greater than 12,000/cu mm. There- 
fore, among 608 patients who had a sore throat as- 
sociated with throat cultures positive for beta-hemo- 
lytic streptococci, there were only 95 who had the 
complete picture of exudative pharyngitis associated 
with group A streptococci and an increase in ASO 
titer. Only 81 patients in this group carried the in- 
fecting organism in their throats for a period longer 
than 21 days after the infection subsided. Less than 
one in every six patients, therefore, would have been 
considered to have an infection comparable in mag- 
nitude to the infections observed in military epi- 
demics which have been associated with rheumatic 
fever attack rates of 3% or greater. 

Strain Virulence and Epidemiological Studies 

An understanding of the relation of strain viru- 
lence of group A streptococci to the incidence of 
rheumatic fever is essential if confusion is to be 
avoided in epidemiological studies and community 
projects now in progress in the United States and in 
several foreign countries. Information about strepto- 
coccal infections limited to the identification of 
group A streptococci in the throat of a given popula- 
tion is not adequate for a full appraisal of the epi- 
demiology of the streptococcal disease in question 
when the latter is sporadic. The routine throat cul- 
ture is still an invaluable tool with which the clini- 
cian may exclude the streptococcal etiology of a sore 
throat when the cultures are negative. When they are 
positive T he may identify a succession of exudative 
pharyngitides as an incipient epidemic of streptococ- 
cal disease. The results of routine throat culturing of 
healthy populations can be misleading, however, if 
no further information is obtained other than the 
presence or absence of beta-hemolytic streptococci. 
Routine throat culturing of children by school nurses 
or in other community programs involving popula- 
tions in which streptococcal disease is not epidemic 
may give misleading information. 

The above considerations argue strongly for the 



U.S. NAVY MEDICAL NEWS LETTER 



19 



continued availability of typing sera for M protein. 
The appearance in any population of a large number 
of strongly M positive strains, particularly when all 
or most are of one type, is indicative of rapid human 
passage of a strain of high virulence and suggests 
conditions under which rheumatic fever should ap- 
pear with greatest frequency and severity. Unfortu- 
nately, there is a tendency for some streptococcal ref- 
erence laboratories, particularly in Europe, to stress 
the identification of streptococcal strains by Griffith's 
slide agglutination test, which is made with antisera 
for T-antigen typing. Although this method will 
identify by another marker (the T antigen) strepto- 
coccal strains which have lost M antigen and will 
thus yield a high percentage of "typable" strains, the 
presence of T antigen bears no relation to strepto- 
coccal virulence and offers little or no help in the 
particular problem of determining the potential 
danger or clinical significance of a given streptococ- 
cal strain. Recent studies have shown that group A 
strains lacking M protein and capsules cannot kill 
hypogammaglobulinemic animals, such as baby 
germ-free mice, and cannot resist phagocytosis by 
the blood of the new-born colostrum-deprived piglet, 
an animal virtually free of antibodies, STOLLER- 
MAN, et al, 1965. 

It has required a good many years of painstaking 
research to identify accurately the kind of strepto- 
cocci most dangerous to man, LANCEFIELD, 
1962. If the approach to the control of diseases due 
to this agent is to progress effectively, increasing 
sophistication in bacteriological procedures for iden- 
tifying the properties of these organisms will be re- 
quired, as well as a better understanding of the prob- 
lem by the clinician who must interpret the results of 
the laboratory report. 

Value of Throat Cultures to the Practitioner 

The above discussion should not be interpreted to 
imply that the throat cultures of patients with sore 
throat are of no value to the practitioner. The de- 
tailed bacteriological study of group A streptococcal 
strains is of importance in the thorough appraisal of 
the epidemiology of streptococcal disease. A selec- 
tive culture for the simple identification of beta-he- 
molytic streptococci on a blood agar plate is of great 
value to the clinician faced with the decision of 
whether or not to treat a patient with sore throat, 
and if so, how vigorously. In the first place, a nega- 
tive culture virtually excludes the need for antibi- 
otics except in certain rare instances (e.g., where 
diphtheria may be suspected). Negative throat cul- 



tures in a succession of patients with exudative phar- 
yngitis strongly suggest outbreaks of adenovirus, or 
at least some viral agent capable of producing a clin- 
ical picture of sore throat indistinguishable from 
streptococcal pharyngitis. 

A sporadic positive culture is more difficult to in- 
terpret. If exudative pharyngitis is associated with 
strongly positive cultures for beta-hemolytic strepto- 
cocci, there is usually no argument. Moreover, if 
several such cases are observed in succession, the 
clinician can promptly recognize an incipient epidem- 
ic, or a succession of passages of a strain, through- 
out a family or a school. By the routine use of the 
throat culture, the clinician becomes aware of the 
nature of the pharyngitis prevalent in his practice at 
different seasons and this strongly influences his de- 
cision as to whether or not treatment should be ad- 
ministered. 

Treatment of the patient and his intimate contacts 
when streptococcal disease becomes prevalent will 
promptly interrupt rapid strain passage and will lead 
to a decrease in strain virulence. Thus, the vigilance 
of the practitioner and his routine use of the throat 
culture are the best protection presently available 
against epidemic streptococcal disease and if prop- 
erly applied should lead to a progressive decrease 
in the prevalence of virulent streptococcal strains 
and to a continued decline in the incidence of rheu- 
matic fever. 

BOUTONNEUSE FEVER 

During April and May 1 963 an outbreak of Bou- 
tonneuse fever in U.S. personnel was reported by a 
naval training command, then designated as a U.S. 
Naval Air Station. Twelve cases were seen and treat- 
ed at the Station Hospital before preventive meas- 
ures could be instituted. 

In April 1964 preventive measures were initiated 
prior to the occurrence of any cases of Boutonneuse 
fever in American personnel. Unfortunately, 2 cases 
were incubating and diagnosed 6 days after preven- 
tive measures had been implemented. 

In April 1 965 preventive measures were instituted 
one week earlier than in 1 964 and this effort proved 
fruitful with 1965 being the first year without the 
incidence of Boutonneuse fever in American person- 
nel in 3 years of record. 

Preventive measures for the control of the vector, 
the brown dog tick, Rhipicephalus sanguineus 
(Latr.) are as follows: 

a. During the month of April, spraying with 1 % 
lindane emulsion, is conducted of all yards of homes 



20 



U.S. NAVY MEDICAL NEWS LETTER 



rented by American personnel in the nearby cities. 
(No local pest control program is available). 

b. Spraying of all yards, playgrounds, athletic 
fields and picnic area aboard the naval training com- 
mand in April with 1 % lindane emulsion. 

c. Establishment of a dog dip tank, containing 
0.5% lindane emulsion, at the station kennels, avail- 
able on a year-round basis, for the control of Canine 
ectoparasites. 

d. Providing an ample supply of tick and flea 
powder for canines and felines through Navy Ex- 
change retail store and the Animal Clinic. 

e. Cutting and burning of vegetation in areas that 
are uninhabited but where persons or children travel 
or play. 

f. Through indoctrination lectures and on a con- 
tinual basis through base news media, a public infor- 
mation program was instituted to apprise personnel 
of the necessity for the control of ticks and other 
ectoparasites. 

Due to proven effectiveness of the tick control 
program, it is projected that a similar program be 
conducted continually. The paramount phase being 
the residual application of insecticide to yards, etc., 
during the first two weeks of April or as soon as the 
increase of tick population is recognized. — 
PrevMed, BuMed. 

CIGUATERA POISONING 

U.S. Dept of HEW, PHS, I Sept 1965 
Press Release. 

Research on poisons found in or produced by 
edible marine life has led to the isolation of and dis- 
covery of an antidote for an ancient poisonous sub- 
stance found in tropical fish around the world. 

Existence of the poison has been known for cen- 
turies, but until recently there has been no antidote 
because of the unknown chemical composition of 
the material and how it works in the body. 

Two professors of zoology and chemistry at the 
University of Hawaii's Marine Laboratory, have iso- 
lated ciguatera poison (sigwaterra), which produces 
a disabling and sometimes fatal disease contracted 
by eating various kinds of tropical fish. 

A member of the team was the first person to 
define the action of the poisor '-sing experimental 
animals. -- v i'iu' 

Experimentation with y?n on laboratory 

animals showed that it opeKj<SJj^y inhibiting enzy- 
matic action, the specific enzyme being cholinester- 
ase. This is the same action manifested by the or- 



gano-phosphate pesticides used widely in this 
country and throughout the world. The Hawaii in- 
vestigators tried drugs used for the treatment of or- 
gano-phosphate poisoning and found that one of 
these, Protopam chloride, used in rats and mice pre- 
viously poisoned with the ciguatera toxin, was' an 
effective antidote if given soon after the onset of 
symptoms. 

The action of the antidote has been proven effec- 
tive in laboratory animals and has kept animals alive 
that had been given over twice the normal lethal 
dose of ciguatera poison. In 1 case where the drug 
was given to humans, it was credited with saving a 
life, but appeared to have serious side effects — flush- 
ing, high blood pressure, feverishness, rapid pulse, 
and broncho-constriction. Two of the patient's 
friends, who had eaten the same fish at the same 
party, died. 

In 1964, in Hawaii, 8 persons were stricken after 
eating a home-cooked dinner consisting mainly of a 
stew containing several types of fish, including the 
entrails and liver. The attending physicians stated 
that they advocate the use of Protopam chloride if 
an early diagnosis of ciguatera fish poisoning can be 
made. 

Symptoms are marked by restlessness, apprehen- 
siveness, profuse sweating, a high white blood cell 
count and diarrhea, followed by involuntary twitch- 
ing of muscles throughout the body, labored breath- 
ing, and the absence of deep tendon reflexes. Cigua- 
tera is considered to be the least virulent form of fish 
poisoning, or ichthyosarcotoxism. The mortality rate 
is about 2 to 3 % . Complete recovery is a matter of 
weeks or months. 

Ciguatera poison still has not been precisely 
defined chemically, but it is known to be found in a 
number of carnivorous fish, including the red 
snapper, the grouper, moray eels, barracuda, lagoon 
sharks, jacks and surgeon-fish. The toxin appears to 
be passed through the food chain by the food fish of 
the carnivores, the smaller reef fish. The smaller fish 
appear to obtain the toxin from feeding on a yet 
unknown alga, but it does not harm them. 

It is found in extremely small concentrations in the 
fish so that scientists could isolate only 1 part by 
weight in approximately 10 million parts of fish. It is 
known that ciguatera toxin is stored in the fish for 
long periods of time and is found in much greater 
concentrations in the liver, gonads and other viscera 
than in the flesh. The toxin in the viscera is many 
times— perhaps as much as 50 times — more concen- 



U.S. NAVY MEDICAL NEWS LETTER 



21 



trated than in the flesh. Nevertheless, the flesh may 
be sufficiently toxic to cause coma or death. 

The team first isolated the substance responsible 
for ciguatera poisoning from the red snapper. Al- 
though identical material has been found in other spe- 
cies, all those implicated in known cases of the poi- 
soning were caught in restricted areas around coral 
reefs of the tropics. The same species of fish may be 
completely safe if caught a few miles away from the 
toxic section of the coral reef. 

The poison has been reported found in such fish 
throughout the tropical belt — in the Caribbean, the 
archipelagoes of the tropical Pacific, and from Mad- 
agascar across the Indian Ocean. It has also been 
found in fish in the Mediterranean. Fish are a val- 
uable source of protein for certain population 
groups in these areas, where dietary protein defi- 
ciency is a problem. 

Ciguatera poisoning was responsible for 3 out- 
breaks reported in scientific journals in 1963 and 

1964 as occurring in Jamaica and involving 61 per- 
sons who ate barracuda. An outbreak in Florida in 

1 962 with similar but mild symptoms, was attributed 
to shellfish. Ciguatera poisoning was suspected but 
the substance was never specifically identified. "Public 
Health Reports' 1 of Sept 1956, reported a series of 
outbreaks in Florida of fish poisoning caused by eat- 
ing barracuda, but again ciguatera poison was not 
specifically identified. 

Ciguatera fish poisoning incidents are recorded at 
least as far back as the discovery of America. Con- 
quistadores in Haiti and Cuba, who followed Co- 
lumbus to America, found local game scarce and 
turned to the sea for food. They ate fish, crusta- 
ceans, mollusks, and an easy-to-capture marine snail 
now known as Burgo (livona pica Linnaeus). Burgo 
was the source of numerous gastrointestinal and nerv- 
ous disorders among the Conquistadores, who gave 
the name of Cigua to the snail and called the dis- 
orders Ciguatera. 

Burgos are still an important part of the diet in 
the remote areas of the isolated islands of the 
French Antilles and continue to be the source of ail- 
ments analagous to those described by chroniclers in 
the Caribbean in the 15th and 16th centuries. 

According to Philip Helfrich, a marine biologist at 
the University of Hawaii Marine Laboratory, who 
published a report in 1961 entitled "Fish Poisoning 
in the Tropical Pacific"; "Ciguatera poisoning ap- 
pears to present the most serious fish poisoning 
problem in the Pacific at the present time, primarily 
due to its widespread occurrence and the multitude 



of highly esteemed food fishes that may harbor the 
undetectable ciguatera toxin." 

Scattered reports over the past 350 years indicate 
that the outbreaks have occurred in the following 
island groups: Ryukyu, Mariana, Caroline, Marshall, 
Gilbert, EUice, Fiji, Samoan, Phoenix, Society, Tua- 
motu, and Marquesas, as well as in New Caledonia, 
the New Hebrides, and tropical Australia. In the 
1940's outbreaks were reported in the Line Islands 
and Midway Island; and in the 1950's, Johnston Is- 
land and Oahu Island in Hawaii. 

TICKS 

The Zoology Laboratory at the U.S. Naval Medi- 
cal Research Unit Number Three, Cairo, Egypt, 
housed in a group of unpretentious buildings, is a 
scientist's treasure trove. Dr. Harry Hoogstraal 
heads a well-organized group supported by special- 
ists, each contributing in his own field. By a highly 
selected process, throughout the years he has col- 
lected and trained a group of excellent technicians 
who perform exact and meticulous duties with a 
high standard of proficiency. These technicians, with 
limited academic backgrounds, have acquired skills 
through training and thus have become major con- 
tributors to the output of this productive laboratory. 
Through the years the laboratory at NAMRU-3 
has accumulated specimens of ticks — particularly 
from Africa and the Near East — from all over the 
world, and the collection now represents one of the 
finest available. Because of Dr. Hoogstraal's reputa- 
tion as a scientist, and his cooperative spirit, his col- 
leagues have contributed much to this collection. 

The collection of ticks is not a museum collection 
but rather a working tool for the principal investiga- 
tor and his workers. Each specimen is carefully la- 
beled as to name, type, stage of development, sex, 
and is given a reference number referring to infor- 
mation in a cross-index. For the past 12 years, this 
writer has watched with interest the collection grow 
from an ordinary but excellent and systematic filing 
into its magnificent present stature. The material has 
been the source of information for more than 100 
published papers on ticks as well as for the book, 
Ticks of the Sudan, and will be used in 3 more vol- 
umes which are under preparation. 

Throughout the vears, Dr. Hoogstraal has sys- 
tematically accuiw; ;d reprints of various publi- 
cations on ticks, aqd: their taxonomy, distribution, 
ecology, and role -fis '-vectors in human and animal 
diseases. From this collection, although incomplete 
but containing most of the worthwhile references in 



22 



U.S. NAVY MEDICAL NEWS LETTER 



the field, Dr. Hoogstraal is developing an annotated 
bibliography, which will systematize this vast 
amount of literature and facilitate its use in the 
preparation of manuscripts. Two books on ticks and 
tick-borne diseases, are being planned. This bibliog- 
raphy, now being worked out as to subject, author, 
geographical area, diseases and vectors, should pro- 
vide investigators with a ready reference covering 
important fields and should save a large amount of 
library time for those interested in specific aspects. 
This coordination of knowledge will prove as useful 
as the many fine original pieces of investigation that 
have been reported by this laboratory. 

Another collection, constantly being enlarged, is 
that of specimens of mammals from Egypt and the 
Sudan. The records and specimens are carefully 
coordinated as to geographic location and the ecto- 
parasites associated with them. These substantiate 
and afford background for ecological studies in in- 
termediate hosts in development of the ticks and the 
animals' potential reservoirs of tick-borne diseases. 
Dr. Hoogstraal is particularly fortunate in having 
Sobhy Gaber, more commonly known as "Soapy," 
(an Egyptian laboratory technician) who has a 
green thumb when it comes to raising ticks. New 
specimens are brought to the laboratory and the life 
cycle carefully followed from egg to adult. At each 
stage of development, the specimens are carefully 
observed and their descriptive characteristics re- 
corded, so that both adult and immature stages of 
the specimens may be readily identified. 

During the rearing process, specimens are selected 
and slides are made. NAMRU-3 records of adult 
specimens and slides on both immature and adult 
forms. Again, the careful, thoughtful planning of 
passed years is demonstrated in the orderly manner 
in which this material is filed available for use in 
identifying specimens received at the laboratory. 

Studies on several new forms of avian plasmodia 
are being carried out. Cooperative studies are con- 
ducted by Dr. Hoogstraal in conjunction with investi- 
gators from the UK, US, India, Asia, Africa and in 
other countries. He is cooperating with Dr. Harold 
Trapido of the Rockefeller Foundation in preparing 
a book on Haemaphysalis ticks. 

A collection of Egyptian "fat rats" (Psammomys 
obesus) was made famous because of their sus- 
ceptibility to diabetes. Each week these much-de- 
sired animals are collected and shipped to laborato- 
ries all over the world. 

One of the services the NAMRU-3 laboratory 
provides is the translation of Russian articles on 

U.S. NAVY MEDICAL NEWS LETTER 



ticks and tick-borne diseases. This literature, which 
is obtained through purchase and exchanges of re- 
prints with Soviet investigators, is translated into 
English by a translator attached to the Unit and pro- 
vides usable documents for the western world. These 
translations are provided to a large distribution 
through ONR London. Approval and appreciation 
of this service is repeatedly expressed by its many 
recipients. 

One cannot leave Dr. Hoogstraal's laboratory 
without noting the artistic and accurate illustrations 
which support the detailed taxonomic descriptions 
so necessary in the preparation of manuscripts. 

Dr. Hoogstraal maintains an unusual library of 
publications on the fauna of Egypt and the Nile Val- 
ley. This personal library contains old and rare pub- 
lications closely related to his work, but always avail- 
able in many larger libraries. 

It is from this unpretentious, well-staffed, excel- 
lent small group of laboratories that so much fine 
material comes on the nature and importance of this 
special group of disease vectors. (CAPT J. R. 
Kingston MC USN, Office of Naval Research, 
Washington, D. C: formerly of the office of Naval 
Research Branch, London.) 

FLEAS 
A CONTINUING PROBLEM 

Waldron, W. G., Los Angeles County Hlth Index, 
38th Rpt Wk, ending 25 Sept 1965. 

Fleas, as vectors of bubonic plague have played 
an important part in the history of mankind. They 
are also a continuing problem as a source of an- 
noyance to both man and animals. 

The fleas most closely associated with man and 
his pets have not been directly implicated as serious 
vectors of disease. However, all arthropods that feed 
upon man must be considered as being of potential 
public health significance. 

In Southern California, the cat flea, Ctenocepha- 
lidis felis, is the most common variety, and the one 
which represents the greatest summer-time nuisance 
to man. Occasionally the flea involved will be the 
dog flea, C. canis, or the human flea Pulex irritans. 
These fleas are frequently, but incorrectly, called 
"sand fleas." They receive this designation because 
their eggs drop from the host animal onto the 
ground where they complete their life cycle. House- 
hold pets are the common hosts. The floor or ground 
is the usual harboring place for fleas. They can be 
easily transported by pets, or clothing, to beds, 

23 



chairs and sofas. From the soil, floor or furniture 
they may leap upon a man or pet to feed. 

The life cycle of the flea passes through four steps 
of development; the egg, the larvae, the pupae and 
the adult. Eggs may be laid upon the host animal, 
then subsequently drop to the floor or soil where 
they hatch into larvae. The larvae spin tiny cocoons 
in which they change into pupae and then into 
adults. Upon emerging from the cocoon, the adult 
flea is ready to feed upon some warm blooded ani- 
mal. 

Fleas subsist upon the blood of their host, be it 
man, bird or animal. On man, the flea usually feeds 
upon the ankles although his bites might eventually 
cover the entire body. The flea is a rapacious feeder 
and may inflict several wounds before his appetite is 
satisfied. The reaction to the bite varies with individ- 



uals and in some, may result in considerable dis- 
comfort and excessive itching. 

Pet owners who have been on a vacation fre- 
quently return to find their home overrun with fleas. 
This situation may be explained by the fact that the 
adult flea can live for several weeks without food. 
The return of the home owner represents a meal to 
the hungry fleas, both old and newly hatched, and at 
such times, they apparently all desire to eat at once. 

Techniques and insecticides * are available to 
abate a flea problem. The usual procedure is to 
deflea the pet, spray the yard with an insecticide and 
vacuum-clean the house and furniture. It must be 
borne in mind that the pet, the house and the yard 
must all be treated the same day. This treatment 
must be repeated one week later. 



* NOTE: For information, call your nearest preventive medicine unit 
disease vector eontro center, or naval district public works office 
(Vector control section, PrevMedDiv) 



KNOW YOUR WORLD 



Did You Know? 



That a serologic test to aid in the diagnosis of 
cases of suspected amebic liver abscess was made 
available to the Virginia State Health Department 
Laboratory by the Laboratory Branch, Communi- 
cable Disease Center, Public Health Service At- 
lanta? 

Results obtained with the indirect hemagglutina- 
tion test indicate that this test is sensitive and spe- 
cific for extra-intestinal amebiasis. Of 127 cases of 
amebic liver abscesses studied, 117 were positive in 
high titers. 

Physicians are encouraged to submit specimens, 
accompanied by detailed histories, from suspected 
cases of extra-intestinal amebiasis to the State 
Health Department Laboratory for evaluation of this 
test. (1) 

That Parkinson's disease takes more than 28,000 
lives a year in the United States with about 40,000 
new cases occurring annually? (2) 

That the whole territory of Afghanistan was de- 
clared free of cholera by notification to the World 
Health Organization on 3 October 1 965? 

When the presence of cholera was noted on 22 
July 1965, the disease had not been reported since 
December 1960. 218 cases and 55 deaths were 
reported, all in the northern provinces. The epi- 



demic was due to both classical cholera and cholera 
El Tor. (3) 

That the 1964 outbreaks of rubella (involving 8 
states) constituted the largest epidemic recorded 
since 1935 (23 states involved)? 

Because of the national importance of this dis- 
ease, particularly in women in the first trimester of 
pregnancy and the resultant congenital malforma- 
tions in newborns, the Biennial Conference of State 
and Territorial Epidemiologists of the USDHEW 
Public Health Service has recommended that rubella 
be placed on the list of nationally reportable dis- 
eases, effective 1 January 1966. (4) 

That an outbreak of poliomyelitis, 47 cases 
through mid-September 1965, occurred in San 
Pedro area of Honduras? 

The date of onset of the first cases is not known. 
In the epidemic area, 59,000 children were given 
Salk-type vaccine; 23,000 under age 9 remain to be 
inoculated. Pending determination of the polio-virus 
type, health authorities are recommending use of the 
trivalent vaccine. The World Health Organization 
has supplied 100,000 doses. The Honduras Ministry 
of Health is requesting an additional 200,000 doses 
from Mexico. (5) 

That poinsettia leaves and mistletoe berries are 
poisonous if eaten? 



24 



U.S. NAVY MEDICAL NEWS LETTER 



A single poinsettia leaf can kill a child and both 
children and adults have died from eating mistletoe 
berries, according to the National Safety Council. 
(6)_ 

That the nation's first Air Pollution Information 
Training Center, devoted entirely to air pollution, 
has been established in New York City? 

The Center is one of two being formed by the 
New York State Action for Clean Air Committee, 
which is sponsored by the New York State Tubercu- 
losis and Respiratory Disease Association, the Asso- 
ciated Industries of New York State, the Medical 
Society of the State of New York and the New York 
State Air Pollution Control Board. 



According to its Director, Dr. Leonard Green- 
burg, former Commissioner of Air Pollution Control 
of New York City, the Center will fill the need of 
researchers, engineers, program administrators and 
the public, and it will serve by fund raising, coordi- 
nating research, collecting and transmitting technical 
information, and training technical personnel and 
educators. (7) 

References 

1 Commonwealth of Virginia Dept of Hlth, Bu of Epid, Morb Rpt 

2. KsfDepnfpnbl^lrith^^This Wk in Public Hlth," 14(37): 

^O Wkfy Epid Record 40(40) : 502 .» Oct 1965. 

USDHEW PHS Morb & Mort Wkly Rpt 13(54). 1, 3U Siepiwto. 

USDHEW Foreign Quarantine Div Epid Summary Or No. 6, 

B 2 un e wls 9 c 65 Stato Bd of Hlth 17(4): 18 1965. 
Mass Dept Public Hlth, "™» Wk ,„ Public 
4 Oct 1965. 



This Wk in Public Hlth," 14(40): 392, 



EDITORIAL DESK 



AVAILABILITY OF PSYCHIATRIC 
RESIDENCIES IN NAVAL HOSPITALS 

The Neuropsychiatric Branch announces the avail- 
ability of a limited number of vacancies in the ap- 
proved Navy psychiatric residency training program. 
Each year there are only twelve openings for Navy 
psychiatric residents beginning at the first year level. 
The Navy hospitals which have residency training 
programs in psychiatry are Bethesda, Maryland; 
Oakland, California; and Philadelphia, Pennsylva- 
nia. Currently, Bethesda and Oakland are fully ap- 
proved for the required three years' training. Phila- 
delphia is approved for two years' training (the third 
year being given at Bethesda); plans are underway 
for obtaining approval for third-year training at Phil- 
adelphia to bring the program there up to full 
accreditation. 

Prospective residents often ask whether any Naval 
hospital can offer completely satisfactory residency 
training utilizing its own facilities and at the same 
time meet the requirements of the review committees 
of the various national approving and accrediting 
bodies. The same question could be asked of any 
hospital, civilian or military. The Navy's psychiatric 
residency training program, as necessary, affiliates 
with local civilian psychiatric facilities in rounding 
out certain aspects of the training program. Affilia- 
tion with state psychiatric hospitals affords extensive 
experience with chronic hospitalized psychotic pa- 
tients. Full time assignments may also be made in 
one or more of the three programs for the purpose 
of acquiring experience in neurology, in psychiatric 

U.S. NAVY MEDICAL NEWS LETTER 



outpatient clinics and in child guidance clinics. Civil- 
ian consultants also participate extensively in the pro- 
gram by conducting regular seminars and supervising 
long term therapy cases. The training experience 
in Navy hospitals includes inpatient and outpatient 
psychiatry ranging through the entire diagnostic 
spectrum. Types of therapy taught and utilized 
include all that are available, i.e., individual and 
group psychotherapy, chemotherapy, somatic ther- 
apy, occupational, and milieu therapies. Both male 
and female patients of all ages are seen for evalua- 
tion and treatment as indicated. Each training hospi- 
tal is located in a metropolitan area where there are 
available academic lectures, short courses, and medi- 
cal schools with excellent psychiatric departments. 
The psychiatric training program is further enhanced 
by relevant research programs of considerable va- 
riety. Thus, it can be seen, the resident is exposed to 
and guided through an extensive range of clinical 
and academic psychiatry. 

Upon completion of residency training, psychia- 
trists have available a wide variety of assignments 
offering diverse opportunities and challenges, rang- 
ing from assignment to the staff of neuropsychiatric 
training hospitals to duty as psychiatrist with a Ma- 
rine Division. Each of the assignments includes 
ongoing professional experience as well as increasing 
responsibilities commensurate with the individual's 
training, experience and motivation. Tours of duty 
are relatively stable, depending upon the individual 
situation and needs of the service. The career Navy 
psychiatrist can expect to progress to Board certifi- 
cation, again depending upon his own motivation, 

25 



and to increasingly responsible assignments up to 
Chief of the Neuropsychiatric Service of a residency 
training hospital. 

The Surgeon General's Consultant Panel in Neu- 
ropsychiatry includes the following members who 
are prominent in their fields. Members of the Panel 
provide ready sources of assistance and guidance in 
dealing with all aspects of Navy neuropsychiatry. 
Francis J,.Braceland, M.D. 
Editor 

The American Journal of Psychiatry 
1700 18th Street, N.W. 
Washington, D.C. 20009 
Howard P. Rome, M.D. 
Head, Psychiatry Section 
Mayo Clinic 
Rochester, Minnesota 
(and President of the American 

Psychiatric Association) 
Cecil L. Wlttson, M.D. 
Dean, College of Medicine and 
Chairman, Department of Neurology 

and Psychiatry 
University of Nebraska 
College of Medicine 
602 South 44 Avenue 
Omaha, Nebraska 
Augustus S. Rose, M.D. 
Professor of Medicine 
Division of Neurology 
School of Medicine 
The Center for the Health 

Sciences 
Los Angeles , California 90024 
Ewald W. Busse, M.D. 
Chairman, Department of Psychiatry 
Duke University Medical Center 
Durham, North Carolina 

Applications are reviewed by the Surgeon Gener- 
al's Advisory Board which selects residents for train- 
ing. Although most residencies start in July of each 
year, for some years residents have been started in 
psychiatry at other times of the year varying with 
vacancies available at individual hospitals which re- 
sult from completion of residency training by other 
individuals. Inquiry for further details can be made 
directly to this office. We invite those interested to 
write to: 

Neuropsychiatry Branch (Code 313) 
Bureau of Medicine and Surgery 
Navy Department 
Washington, D.C. 20390 



26 



NOT JUST ANOTHER BABY 

Mark David Lyons, son of David Lyons HN and 
Mrs. Lyons was born on July 4th. Two and a half 
months later in September he was discharged from 
our hospital. 

There are many babies born at USNH Jackson- 
ville; however, this is not just another baby. Little 
Mark was delivered by Dr. Blair three months pre- 
maturely and weighed 1 pound 11 oz. His weight 
declined the first few days and, at one point, he 
weighed 1 pound 5 oz. 

He spent two months in an incubator and was fed 
for the first three weeks through a levin tube before 
changing to a bottle. Under the watchful eye of Drs. 
Cilento, and Williams and the nursery staff, Mark 
started to gradually gain weight. Recently, he was 
taken out of the incubator and, at the time of his 
discharge, he weighed 5 pounds Va oz. 

Infants born in this weight range seldom survive 
due to generalized inability of all their organ-systems 
to function, particularly the lungs. Moreover, they 
are deprived of needed nutritional stores and are vir- 
tually devoid of all antibodies to fight infection. 
Amazingly enough, infant Mark never experienced 
any respiratory difficulty. His uncomplicated story in 
the nursery is the envy of all preemies. 

September 20th was a happy day in the life of the 
Lyons family. After more than two and one half 
months, Carol and Dave will be able to hold the 
"little fella" (to use one of Dave's sayings) and take 
over the duties of a mother and father. 



I ■■■■■! 

#35 9m. 



s 




rh P 5 tU f £ ™ al ??*t T a *° r) are CAPT F - W. Burke MC. 
Chief of OB-GYN; Dr. Erbs, Dave, Carol, Dr. Williams, 
M,ss Nelson and Dr. Cilento. This is the staff that took 
care of Mark during his stay in the hospital. Miss Nel- 
son w Head Nurse of the E-Building.^Service Informa- 
tion Officer, U.S. Naval Hospital, Jacksonville, Florida. 

U.S. NAVY MEDICAL NEWS LETTER 



ETHER PEROXIDES 

A recent occurrence at Chico State College em- 
phasizes the need for special procedures and precau- 
tions in the handling and storage of ether com- 
pounds. An assistant professor of chemistry at the 
college, making a routine check of the contents of a 
storeroom, noticed a partially full five gallon can of 
isopropyl ether and recalled reading recently about 
potentially dangerous properties of certain ethers. 
The article he remembered had stressed the property 
of many ether compounds to form peroxides under 
certain conditions of storage or use, and that these 
peroxides were potentially very powerful explosives 
which could be initiated by heat or shock. 

The authorities were alerted and a special army 
detonation squad was called in to assist in disposal 
of the suspect container. After appropriate precau- 
tion, the container was removed to an isolated loca- 
tion and exploded with a detonating substance. The 
resulting explosion, far greater than could be attrib- 
uted to the initiating charge itself, was violent 
enough to rattle windows almost a mile away and was 
heard over three miles away. 

Other recently reported incidents illustrate the po- 
tential hazard of ether peroxides. At the University 
of Maine, two glass bottles of slightly less than one 
gallon capacity, labeled isopropyl ether, were found 
in a basement storeroom and apparently had been 
there for more than twenty years. Both bottles were 
nearly one-third full of a crystalline solid under the 
liquid upper layer. Aware of the peroxide hazard, 
the school authorities removed the bottles to a dump 
at the edge of town and then threw stones at the 
bottles to break them. The report goes on to state, 
"When the first stone struck, there was a violent ex- 
plosion which blasted mud and debris over the sur- 
rounding landscape." 

Unfortunately, not all the incidents have had 
happy endings. A chemist was attempting to loosen 
the stuck glass cap on a pint bottle of isopropyl 
ether and just as the cap broke loose the bottle ex- 
ploded violently and the man died from the injuries 
received. 

There are a great many different ether com- 
pounds, all being grouped in the same chemical "fam- 
ily" because of similarity in chemical structure and 
behavior. Other common families are the alcohols, 
acids, esters, etc. The best known and most com- 
monly used ether is ethyl ether, also known as dieth- 
yl ether and sometimes as "sulfuric" ether. This 
compound finds frequent use as an industrial and 
laboratory solvent, and also is the ether most com- 

U.S. NAVY MEDICAL NEWS LETTER 



monly used as an anesthetic. Another anesthetic 
ether is divinyl ether. Isopropyl ether has been advo- 
cated as a safer variety for many laboratory uses, 
because it is considerably less volatile than ethyl 
ether. Anhydrous or absolute ether is ethyl ether 
with all traces of impurities and water removed, 
making it chemically pure. There are many, many 
other ether compounds but these are the most com- 
mon ones. 

At the present time, little is known about the mech- 
anism which causes the spontaneous formation of 
peroxides in various ethers, nor is the exact chemical 
nature of these peroxides known. There appears to 
be ample evidence however that all the ethers men- 
tioned above are subject to this hazardous property. 

Experience has indicated that while the formation 
of peroxides can occur under any condition, the 
reaction apparently is accelerated by exposure to 
light, and oxygen from the air. Contact with certain 
metals, particularly iron and copper, appears to in- 
hibit peroxide formation but there is no evidence 
available yet to prove that the formation of peroxides 
can be entirely prevented. 

The following facts regarding formation of perox- 
ides seem to be established: 

1 . Exposure to the air, as in opened and partially 
emptied containers, accelerates formation of perox- 
ides. 

2. Exposure to light, as would occur in the case 
of storage in clear glass bottles, encourages forma- 
tion. 

3. Absolute ether undergoes oxidation (forma- 
tion of peroxides) much more readily than ethyl 
ether containing a few tenths of a per cent of water. 

4. Isopropyl ether may be more vulnerable than 
other commonly used ethers to peroxide formation 
on long storage. 

5. Heat encourages the inception of oxidation. 

6. Distillation of ether containing peroxides 
greatly aggravates the potential hazard since the por- 
tion remaining in the heated distilling flask becomes 
more and more concentrated as the operation pro- 
ceeds, in addition to the possibility of accelerated 
oxidation due to heat. 

7. Some but not necessarily all ether peroxides 
are crystalline solids which would be plainly visible 
at the bottom of a container. Also, some are water 
soluble and others are not. 

The following general preventive measures are rec- 
ommended for minimizing the hazards of peroxide 
formation in ethers: 



f 



27 



1. Glass containers of all sizes should be avoided 
whenever possible. 

2. All containers should be dated so that the age 
of the contents may be determined. 

3. Isopropyl and absolute ethers should not be 
kept for more than six months, ethyl and other 
ethers for not more than one year. 

4. Ether should be stored in as cool a location as 
feasible, (but not stored in refrigerators unless ex- 
plosion-proof). 

5. Ether should always be tested for peroxide 
content before any distillation procedure, and of 
course should not be used if peroxides are found to 
be present. 

6. Do not attempt to open any containers of un- 
certain age or condition, or whose cap or stopper is 

tightly stuck. 

7. Manufacturers should be contacted to learn 
any general recommendations regarding safe han- 
dling in storage and use, and any specific recommen- 
dations for the addition of inhibitors to prevent per- 
oxide formation wherever possible. Manufacturers 
can also recommend regarding the best methods for 
chemical test to detect peroxide content, and for 
possible removal of peroxides by chemical means. 

8. In addition to all the above, special precau- 
tions are appropriate to hospital use of ether for an- 
esthesia. Section A 1113, Appendix A of N.B.F.U. 
No. 56, Standard for the Use of Flammable Anes- 
thetics, states as follows: 

"The Committee on Hospitals is cognizant of sug- 
gestions that the detonation of ether peroxides 
formed by the oxidation of ether over a period of 
time may be cause of explosions in anesthesia ma- 
chines. This has not as yet been experimentally ver- 
ified, but until further information is secured, fre- 
quent emptying of the ether bottle and cleaning of 
the ether evaporator inside anesthetizing locations 
would be a simple and desirable precaution." 

Finally, if suspect containers are found in storage, 
do not undertake their removal and disposition on 
your own! Call the local fire authority. While there 
appears to be no evidence that peroxides in storage 
containers have exploded spontaneously, or even 
under gentle handling, there can be no assurance 
that this might not occur. Let the local fire authority 
determine the safest procedure for disposition of the 
material.— State of California, Public Safety 
Agency. 



REPLACEMENT OF BLOOD USED BY 

FAMILY MEMBERS OF OVERSEAS 

SERVICEMEN 

The following information has been received from 
the American National Red Cross: 

"In conformity with our continuing policy of be- 
ing of service to military personnel overseas and in 
recognition of the active support of the American 
Red Cross Blood Program by military personnel, anv 
request made through Red Cross by a serviceman 
overseas for blood replacement for immediate family 
members hospitalized in the United States will be 
accepted for the total amount of blood actually 
transfused (contingent only upon the hospital's ac- 
ceptance of Red Cross blood or blood credits). Such 
requests will be assigned by national headquarters to 
a Red Cross blood center, usually the nearest to the 
hospital or the one which may have received blood 
donations from the serviceman's stateside station. 
Donation of blood overseas is neither a prerequisite 
nor a requirement." 

REIMBURSING COSTS UNDER 
THE MEDICARE PROGRAM 

Representatives of the insurance industry met 
during the 3rd week in October at Social Security 
headquarters in Baltimore to discuss the principles 
to be followed in reimbursing administrative agents 
for their costs in receiving and paying hospital and 
medical bills under the medicare program. 

Under the law the Government will not make di- 
rect payments to physicians, hospitals, and institu- 
tions which provide care to persons 65 and over 
unless the provider of services elects to be paid 
directly. 

Hospitals, nursing homes, and home health care 
agencies may nominate administrative agents to act 
as fiscal intermediaries between them and the Feder- 
al Government in determining payments due and in 
paying the bills. 

The Secretary of Health, Education, and Welfare, 
will select "carriers" to determine what are reason- 
able charges for the reimbursement of physicians 
and providers of medical services outside the hospi- 
tal and will pay those bills. 

Under agreements or contracts entered with the 
Secretary of Health, Education, and Welfare, admin- 
istrative agents will receive advances of funds for the 
purpose of making benefit payments and as a work- 
ing fund to cover administrative expenses. 

"The Government will be placing great reliance 
on the responsibility, the efficiency, and the expe- 
rience of private insurance organizations," Robert M. 



28 



U.S. NAVY MEDICAL NEWS LETTER 



Ball, Commissioner of Social Security, told the 
group meeting this week. "The effectiveness with 
which they carry out their functions as agents under 
the program will govern the effectiveness of the pro- 
gram itself," he said. 

The consultant group is one of nine work groups 
that are being called upon to contribute experience 
and advice to help the Social Security Administra- 
tion develop policies for the administration of the 
new program of health insurance for the aged. 

Results of the discussions at this week's meeting 
will be presented to the Health Insurance Benefits 
Advisory Council, a permanent 16-member council 
to be appointed in accordance with the law by the 
Secretary of Health, Education, and Welfare. The 
Advisory Council will advise the Government on ad- 
ministrative policies and on the formulation of regu- 
lations for the medicare program. — USDHEW, So- 
cial Security Administration. 

PRINCIPLES FOR REIMBURSING 

HOSPITALS UNDER THE 

MEDICARE PROGRAM 

Principles for reimbursing hospitals under the new 
medicare program were discussed by an advisory 
group of 31 consultants, meeting October 11 and 
12, at social security headquarters in Baltimore. 

The results of the discussions will be used to de- 
velop regulations for the payment of hospital costs 
for the 19 million people 65 and over who will be 
covered by the program of hospital insurance for the 
aged when it goes into operation next July. 

The law specifies that hospitals shall be reim- 
bursed for the reasonable cost of care provided the 
aged. They will be paid for their actual costs, deter- 
mined under a national formula which will be de- 
signed to take account of differences in cost from 
hospital to hospital, reflecting such factors as differ- 
ences in the quality and intensity of care they pro- 
vide. 

"By meeting the full reasonable cost of care, the 
law will provide financial support for the best qual- 
ity of care that hospitals can provide," Robert M. 
Ball, Commissioner of Social Security, told the 
group. 

The advisory group, composed of representatives 
of the medical profession, hospitals, health insurance 
organizations, and others involved in the provision 
of health services, is one of nine work groups that 
will be called upon to contribute experience and ad- 
vice to help the Social Security Administration devel- 
op policies for the administration of the new pro- 



grams hospital insurance and medical insurance set 
up in the medicare legislation. 

"Hospitals will no longer have to struggle as they 
have with the inability of older people to pay for 
their hospital care,' 1 Ball said. "Their losses from 
bad debts and from providing care free to aged pa- 
tients will be reduced and will not have to be in- 
cluded in charges to paying patients." — USDHEW, 
Social Security Administration. 

NAVY CORPSMAN CITED FOR BRAVERY 

Hospitalman George M. Aurelius became the sec- 
ond Navy Corpsman to be decorated with the 
Bronze Star Medal with Combat "V" recently when 
the award was presented by Maj. Gen. Lewis W. 
Walt, Commanding General of the 3rd Marine Am- 
phibious Force. 

Aurelius received his award while serving with D 
Co., 3rd Reconnaissance Bn. 




Hospitalman George M. Aurelius is congratulated by 
Maj. Gen. Lewis W. Walt, Commanding General of the 
3rd Marine Amphibious Force, after being presented the 
Bronze Star with Combat "V". He was cited for admin- 
istering aid to two marines wounded on a mission north 
of the DaNang airfield. 

On July 12, Aurelius was accompanying a search- 
and-clear mission of a village north of the DaNang 
airfield when the patrol received heavy small arms 
fire from the Viet Cong. 

The platoon was pinned down by fire and sus- 
tained two casualties. Aurelius quickly and compe- 
tently administered aid to the injured men, exposing 
himself to enemy fire. 

He hurt his knee while rushing to the wounded 
marines but refused evacuation for himself, knowing 
he was the only corpsman attached to the company. 
— Technical Information Office, BuMed. 



U.S. NAVY MEDICAL NEWS LETTER 



29 



DEPARTMENT OF THE NAVY 

U. S. NAVAL MEDICAL SCHOOL 

NATIONAL NAVAL MEDICAL CENTER 

BETHESDA, MARYLAND 20014 



POSTAGE AND FEES PAID 
NAVY DEPARTMENT 



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U.S. NAVY MEDICAL NEWS LETTER